Provider Demographics
NPI:1073020392
Name:WATERSON, MELISSA SUE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:WATERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15558 WINN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AR
Mailing Address - Zip Code:72959-9427
Mailing Address - Country:US
Mailing Address - Phone:479-879-1061
Mailing Address - Fax:
Practice Address - Street 1:15558 WINN CREEK RD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AR
Practice Address - Zip Code:72959-9427
Practice Address - Country:US
Practice Address - Phone:479-879-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-17-28616103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty