Provider Demographics
NPI:1639104870
Name:WATT, KIM A (LPC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:WATT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:WATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:325 NW 21ST AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1174
Mailing Address - Country:US
Mailing Address - Phone:503-880-3288
Mailing Address - Fax:
Practice Address - Street 1:325 NW 21ST AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1174
Practice Address - Country:US
Practice Address - Phone:503-880-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WCBBCMedicare ID - Type Unspecified