Provider Demographics
NPI:1174256911
Name:WATSON, GLEN (CASAC-T)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 HERKIMER ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-6129
Mailing Address - Country:US
Mailing Address - Phone:347-358-2723
Mailing Address - Fax:
Practice Address - Street 1:764 E 176TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4606
Practice Address - Country:US
Practice Address - Phone:718-542-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)