Provider Demographics
NPI:1356471122
Name:WATSON, HERSCHELIA
Entity Type:Individual
Prefix:
First Name:HERSCHELIA
Middle Name:
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 1:2605 E WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:LITTTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-5968
Mailing Address - Country:US
Mailing Address - Phone:562-787-3130
Mailing Address - Fax:
Practice Address - Street 1:201 WEST 2ND
Practice Address - Street 2:
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086-2804
Practice Address - Country:US
Practice Address - Phone:501-676-3151
Practice Address - Fax:501-676-3152
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1356471122Medicaid