Basic Information
| Provider Information | |||||||||
| NPI: | 1992201198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5025 N PAULINA ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606402772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732719040 | ||||||||
| FaxNumber: | 7732935506 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 S MICHIGAN AVE STE 928 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122483190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180.011382 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 14230228 | 01 | IL | CAQH | OTHER |