Provider Demographics
NPI:1922632629
Name:WATSON, ANGELA DIANTHA BLACKBURN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DIANTHA BLACKBURN
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 S 700 E STE 203
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3075
Mailing Address - Country:US
Mailing Address - Phone:801-268-4887
Mailing Address - Fax:801-268-4880
Practice Address - Street 1:2845 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7147
Practice Address - Country:US
Practice Address - Phone:801-930-5703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician