Provider Demographics
NPI:1255097499
Name:WATSON, SUSAN (LGPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 E RIDGELY RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5239
Mailing Address - Country:US
Mailing Address - Phone:410-952-2103
Mailing Address - Fax:
Practice Address - Street 1:1010 DULANEY VALLEY RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2702
Practice Address - Country:US
Practice Address - Phone:410-565-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health