Provider Demographics
NPI:1851934327
Name:WATSON, TOMMY JR
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:WATSON
Suffix:JR
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:IMPACT BEHAVIOR SERVICES LLC
Mailing Address - Street 2:1406 ESPLANADE
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70116
Mailing Address - Country:US
Mailing Address - Phone:504-304-4097
Mailing Address - Fax:504-218-7962
Practice Address - Street 1:IMPACT BEHAVIOR SERVICES LLC
Practice Address - Street 2:1406 ESPLANADE
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70116-7011
Practice Address - Country:US
Practice Address - Phone:504-304-4097
Practice Address - Fax:504-218-7962
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1821358300Medicaid