Provider Demographics
NPI:1164403085
Name:WATSON, KELLE A (MA LPC)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:A
Last Name:WATSON
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:KELLE
Other - Middle Name:AUDREY
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LPC
Mailing Address - Street 1:780 LYNNHAVEN PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7351
Mailing Address - Country:US
Mailing Address - Phone:757-301-8747
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 110
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7351
Practice Address - Country:US
Practice Address - Phone:757-301-8747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005236101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015758110002Medicaid