Provider Demographics
NPI:1760146278
Name:WATSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:3300 E CENTRAL TEXAS EXPY STE 301
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5674
Mailing Address - Country:US
Mailing Address - Phone:254-442-0149
Mailing Address - Fax:
Practice Address - Street 1:3300 E CENTRAL TEXAS EXPY STE 301
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5674
Practice Address - Country:US
Practice Address - Phone:254-213-9348
Practice Address - Fax:254-442-0149
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83519101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty