Provider Demographics
NPI:1114206216
Name:WATSON, SHANA LYNN
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:LYNN
Last Name:WATSON
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 1:6767 FOREST HILL AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-1856
Mailing Address - Country:US
Mailing Address - Phone:804-901-7823
Mailing Address - Fax:804-901-7823
Practice Address - Street 1:6767 FOREST HILL AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1856
Practice Address - Country:US
Practice Address - Phone:804-901-7823
Practice Address - Fax:804-901-7823
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1640101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health