Provider Demographics
NPI:1740391069
Name:WATFORD, VIRGINIA LEIGH (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:LEIGH
Last Name:WATFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 SANTA CRUZ STREET
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3318
Mailing Address - Country:US
Mailing Address - Phone:949-494-6823
Mailing Address - Fax:
Practice Address - Street 1:27405 PUERTA REAL
Practice Address - Street 2:SUITE 150
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6314
Practice Address - Country:US
Practice Address - Phone:949-348-2850
Practice Address - Fax:949-348-2850
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP5281Medicare ID - Type Unspecified