Provider Demographics
NPI:1033541115
Name:WATSON, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S HUBBARDS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4004
Mailing Address - Country:US
Mailing Address - Phone:972-921-0349
Mailing Address - Fax:
Practice Address - Street 1:115 ROCKWOOD LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9415
Practice Address - Country:US
Practice Address - Phone:606-436-5761
Practice Address - Fax:606-435-0817
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY246778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health