Provider Demographics
NPI:1740387935
Name:WATSON, RICHARD A
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-1033
Mailing Address - Country:US
Mailing Address - Phone:269-429-7727
Mailing Address - Fax:269-429-5754
Practice Address - Street 1:5675 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-1033
Practice Address - Country:US
Practice Address - Phone:269-429-7727
Practice Address - Fax:269-429-5754
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009577101Y00000X
MI6301012216103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP208915080OtherBLUE CROSS PIN