Provider Demographics
NPI:1477658995
Name:WATSON, SUE ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:ELLEN
Last Name:WATSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:ELLEN
Other - Last Name:PHARIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1825 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-3409
Mailing Address - Country:US
Mailing Address - Phone:870-630-2328
Mailing Address - Fax:870-630-2348
Practice Address - Street 1:1825 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3409
Practice Address - Country:US
Practice Address - Phone:870-630-2328
Practice Address - Fax:870-630-2348
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000030031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3922857Medicaid
TN3922858Medicare ID - Type UnspecifiedPROVIDER #