Provider Demographics
NPI:1164534384
Name:SHEPARDSON WATSON, KIM (LCSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SHEPARDSON WATSON
Suffix:
Gender:F
Credentials:LCSW
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 94
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333
Mailing Address - Country:US
Mailing Address - Phone:860-739-6974
Mailing Address - Fax:860-739-5290
Practice Address - Street 1:29 CHESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333
Practice Address - Country:US
Practice Address - Phone:860-739-6974
Practice Address - Fax:860-739-5290
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002624104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004255875Medicaid
CT004255875Medicaid