Provider Demographics
NPI:1124175500
Name:WATFORD GAMBLE, KATRINA ANN (MA,NCC,LPC)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:ANN
Last Name:WATFORD GAMBLE
Suffix:
Gender:F
Credentials:MA,NCC,LPC
Other - Prefix:MRS
Other - First Name:KATRINA
Other - Middle Name:A
Other - Last Name:WATFORD GAMBLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, NCC,LPC
Mailing Address - Street 1:PO BOX 64986
Mailing Address - Street 2:204 RUNWAY RD
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-0986
Mailing Address - Country:US
Mailing Address - Phone:910-429-2222
Mailing Address - Fax:910-429-2222
Practice Address - Street 1:111 LAMON ST STE 212
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4957
Practice Address - Country:US
Practice Address - Phone:910-429-2222
Practice Address - Fax:910-429-2222
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NC6574101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor