Provider Demographics
NPI:1063468817
Name:WATTERS, NICHOLAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:WATTERS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6278
Mailing Address - Country:US
Mailing Address - Phone:270-401-4107
Mailing Address - Fax:270-209-0872
Practice Address - Street 1:240 W DIXIE,
Practice Address - Street 2:SUITE 5-B
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1575
Practice Address - Country:US
Practice Address - Phone:270-401-4107
Practice Address - Fax:270-209-0872
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11574941OtherCAQH
KY7100266120Medicaid
KY00205001Medicare PIN
KY0690948Medicare PIN
KY7100266120Medicaid
KY0762343Medicare PIN
KY0763543Medicare PIN
KY00201003Medicare PIN
11574941OtherCAQH
KY0974716Medicare PIN
KY00200003Medicare PIN
KY00199003Medicare PIN
KY00207001Medicare PIN