Provider Demographics
NPI:1366673584
Name:WATSON, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
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:PO BOX 528
Mailing Address - Street 2:ATTN: BEHAVIORAL HEALTH
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-6700
Mailing Address - Fax:907-543-6712
Practice Address - Street 1:324 RADIO STREET
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-6700
Practice Address - Fax:907-543-6712
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid