Provider Demographics
NPI:1427184605
Name:WATT, MARK JOSEPH (PHD, JD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:WATT
Suffix:
Gender:M
Credentials:PHD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5106
Mailing Address - Country:US
Mailing Address - Phone:307-745-5414
Mailing Address - Fax:307-745-5138
Practice Address - Street 1:526 REGENCY DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5106
Practice Address - Country:US
Practice Address - Phone:307-745-5414
Practice Address - Fax:307-745-5138
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY199103T00000X
CO1751103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist