Basic Information
Provider Information | |||||||||
NPI: | 1841324043 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATSON | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTLER | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5575 CAPISTRANO AVE | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 934224264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057921400 | ||||||||
FaxNumber: | 8059296440 | ||||||||
Practice Location | |||||||||
Address1: | 5575 CAPISTRANO AVE | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 934224264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057921400 | ||||||||
FaxNumber: | 8059296440 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 23293 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.