Provider Demographics
NPI:1013252071
Name:WATSON, DEMETRUIS RENEE
Entity type:Individual
Prefix:
First Name:DEMETRUIS
Middle Name:RENEE
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 1:3507 LYNHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1412 N BROADWAY STE 204
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-3157
Practice Address - Country:US
Practice Address - Phone:859-412-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0069891041C0700X
KY2589571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical