Provider Demographics
NPI:1679770507
Name:WATSON, LUCAS NATHANIEL (LMSW)
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:NATHANIEL
Last Name:WATSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:HAZELHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-0847
Mailing Address - Country:US
Mailing Address - Phone:601-894-1323
Mailing Address - Fax:601-968-0079
Practice Address - Street 1:34132 HWY 28 EAST
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059
Practice Address - Country:US
Practice Address - Phone:601-894-1323
Practice Address - Fax:601-968-0079
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM0861104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07108853Medicaid