Provider Demographics
NPI:1164068763
Name:WATSON, LATRECE
Entity Type:Individual
Prefix:
First Name:LATRECE
Middle Name:
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 1:6400 E BROAD ST STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2979
Mailing Address - Country:US
Mailing Address - Phone:614-655-3345
Mailing Address - Fax:614-317-4689
Practice Address - Street 1:6400 E BROAD ST STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2979
Practice Address - Country:US
Practice Address - Phone:614-655-3345
Practice Address - Fax:614-317-4689
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health