Provider Demographics
NPI:1811207137
Name:WATSON, BRENDA MARIE (M ED, LPC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 JUBILEE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCITON
Mailing Address - State:CO
Mailing Address - Zip Code:81506
Mailing Address - Country:US
Mailing Address - Phone:970-241-8056
Mailing Address - Fax:
Practice Address - Street 1:669 JUBILEE CT
Practice Address - Street 2:
Practice Address - City:GRAND JUNCITON
Practice Address - State:CO
Practice Address - Zip Code:81506
Practice Address - Country:US
Practice Address - Phone:970-241-8056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4396101YP2500X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional