Provider Demographics
NPI:1770028375
Name:WATSON, CRYSTAL DIANE (MSW, SWAICL)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DIANE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSW, SWAICL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E MAIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1146
Mailing Address - Country:US
Mailing Address - Phone:509-488-5611
Mailing Address - Fax:509-488-0166
Practice Address - Street 1:425 E MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1146
Practice Address - Country:US
Practice Address - Phone:509-488-5611
Practice Address - Fax:509-488-0166
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2020-02-03
Deactivation Date:2019-12-16
Deactivation Code:
Reactivation Date:2020-01-13
Provider Licenses
StateLicense IDTaxonomies
WA60865152101YM0800X, 101YM0800X
WA61021724101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2144691Medicaid