Provider Demographics
NPI:1376109256
Name:WATSON, WANDA DUREN (LPC)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:DUREN
Last Name:WATSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 SHALLOWFORD RD BLDG H4
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:770-403-4204
Mailing Address - Fax:
Practice Address - Street 1:4343 SHALLOWFORD RD BLDG H4
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:770-403-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional