Provider Demographics
NPI:1730672783
Name:WATT, LARISA RACHAEL (BA, LCDCII, QBHS)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:RACHAEL
Last Name:WATT
Suffix:
Gender:F
Credentials:BA, LCDCII, QBHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9363
Mailing Address - Country:US
Mailing Address - Phone:330-424-1468
Mailing Address - Fax:
Practice Address - Street 1:964 N MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9363
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161674101YA0400X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0392156Medicaid