Provider Demographics
NPI:1275653370
Name:WATSON, CASEY FULTON
Entity Type:Individual
Prefix:MR
First Name:CASEY
Middle Name:FULTON
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 S PINKERTON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-2439
Mailing Address - Country:US
Mailing Address - Phone:903-670-3292
Mailing Address - Fax:903-670-3292
Practice Address - Street 1:226 S PINKERTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-2439
Practice Address - Country:US
Practice Address - Phone:903-670-3292
Practice Address - Fax:903-670-3292
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320700000X
TX100477320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness