Provider Demographics
NPI:1790138667
Name:WATTERSON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WATTERSON
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 1:140 ASPEN SQ
Mailing Address - Street 2:SUITE B
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5323
Mailing Address - Country:US
Mailing Address - Phone:225-250-9654
Mailing Address - Fax:225-412-3820
Practice Address - Street 1:140 ASPEN SQ
Practice Address - Street 2:SUITE B
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5323
Practice Address - Country:US
Practice Address - Phone:225-250-9654
Practice Address - Fax:225-412-3820
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000Medicaid