Provider Demographics
NPI:1477962306
Name:WATSON, ANDREA MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:38236-2617
Mailing Address - Country:US
Mailing Address - Phone:951-603-4344
Mailing Address - Fax:
Practice Address - Street 1:2235 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TN
Practice Address - Zip Code:38236-2617
Practice Address - Country:US
Practice Address - Phone:951-603-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1717106H00000X
CA106692106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477962306Medicaid