Provider Demographics
NPI:1093486920
Name:KEMP WATSON, SHANNAN K (MSW, LISW-S)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:K
Last Name:KEMP WATSON
Suffix:
Gender:F
Credentials:MSW, LISW-S
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 118
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-0118
Mailing Address - Country:US
Mailing Address - Phone:740-695-9447
Mailing Address - Fax:740-695-8895
Practice Address - Street 1:255 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1040
Practice Address - Country:US
Practice Address - Phone:740-695-9447
Practice Address - Fax:740-695-8895
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS16010661041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0460514Medicaid