Provider Demographics
NPI:1376219790
Name:WATSON, SHELBY (BS)
Entity Type:Individual
Prefix:MISS
First Name:SHELBY
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 POPLAR FOREST RD
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-4520
Mailing Address - Country:US
Mailing Address - Phone:757-304-7277
Mailing Address - Fax:
Practice Address - Street 1:20566 TIMBERLAKE RD STE A
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7221
Practice Address - Country:US
Practice Address - Phone:434-239-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-180699106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
9118772604OtherUNITEDHEALTHCARE