Provider Demographics
NPI:1518234954
Name:WATSON, GLEN HAROLD JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:HAROLD
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 ELFINWING LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-7008
Mailing Address - Country:US
Mailing Address - Phone:850-383-2802
Mailing Address - Fax:
Practice Address - Street 1:FLORIDA STATE HOSPITAL
Practice Address - Street 2:BUILDING 1000
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1000
Practice Address - Country:US
Practice Address - Phone:850-663-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist