Provider Demographics
NPI:1174179279
Name:WATSON, CYRILLA (RBT)
Entity Type:Individual
Prefix:
First Name:CYRILLA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 S FEDERAL WAY STE 103426
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5204
Mailing Address - Country:US
Mailing Address - Phone:805-668-8961
Mailing Address - Fax:208-416-6922
Practice Address - Street 1:3527 S FEDERAL WAY STE 103426
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5204
Practice Address - Country:US
Practice Address - Phone:805-668-8961
Practice Address - Fax:208-416-6922
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-19-95584106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARBT-19-95584OtherBACB BOARD