Provider Demographics
NPI:1407304314
Name:WATSON, LISA (MDIV)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2929
Mailing Address - Country:US
Mailing Address - Phone:612-483-4994
Mailing Address - Fax:
Practice Address - Street 1:5407 EXCELSIOR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2929
Practice Address - Country:US
Practice Address - Phone:612-483-4994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist