Provider Demographics
NPI:1558659755
Name:WATSON, SHONDRA T (LPC)
Entity Type:Individual
Prefix:MS
First Name:SHONDRA
Middle Name:T
Last Name:WATSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHONDRA
Other - Middle Name:T
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3415 CUSTER ST STE D
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4328
Practice Address - Country:US
Practice Address - Phone:920-652-9310
Practice Address - Fax:920-652-9316
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6537-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558659755Medicaid