Provider Demographics
NPI:1982029328
Name:WATHEN, JAMES III
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WATHEN
Suffix:III
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 1:4710 CHAMPIONS TRACE LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3495
Mailing Address - Country:US
Mailing Address - Phone:502-287-0642
Mailing Address - Fax:502-287-0644
Practice Address - Street 1:4710 CHAMPIONS TRACE LN
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3495
Practice Address - Country:US
Practice Address - Phone:502-287-0642
Practice Address - Fax:502-287-0644
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health