Provider Demographics
NPI:1568551331
Name:WATTERSON, JOHN AMBROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:AMBROSE
Last Name:WATTERSON
Suffix:
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 1:4101 PARKSTONE HEIGHTS DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7396
Mailing Address - Country:US
Mailing Address - Phone:512-306-0663
Mailing Address - Fax:512-306-8086
Practice Address - Street 1:4101 PARKSTONE HEIGHTS DR
Practice Address - Street 2:SUITE 260
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-7396
Practice Address - Country:US
Practice Address - Phone:512-306-0663
Practice Address - Fax:512-306-8086
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3659103T00000X
TX002664-043004106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0074HVOtherBCBS PROVIDER NUMBER
TX00950HMedicare ID - Type Unspecified