Basic Information
| Provider Information | |||||||||
| NPI: | 1821055096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATT | ||||||||
| FirstName: | MELVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9340 NE 76TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986623721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602534912 | ||||||||
| FaxNumber: | 3602535170 | ||||||||
| Practice Location | |||||||||
| Address1: | 3919 S 19TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537525677 | ||||||||
| FaxNumber: | 2537568936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY00002583 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8384976 | 05 | WA | MEDICAID |