Provider Demographics
NPI:1659312809
Name:WATT, KATHY (NP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 BLUE STAR HWY
Mailing Address - Street 2:CLINIC BILLING DEPARTMENT
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7758
Mailing Address - Country:US
Mailing Address - Phone:269-637-1115
Mailing Address - Fax:
Practice Address - Street 1:930 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7758
Practice Address - Country:US
Practice Address - Phone:269-637-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141333207Q00000X, 363LF0000X
MI6301007946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500D111330OtherBC/BS
MI680C946400OtherBC/BS
MID16189072Medicare ID - Type UnspecifiedMEDICARE
MI500D111330OtherBC/BS