Provider Demographics
NPI:1164768594
Name:WATSON, MARY KATHLEEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
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 1:500 OWNBY ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2233
Mailing Address - Country:US
Mailing Address - Phone:575-542-3252
Mailing Address - Fax:
Practice Address - Street 1:500 OWNBY ST
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2233
Practice Address - Country:US
Practice Address - Phone:575-542-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM351462103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool