Provider Demographics
NPI:1255594297
Name:WATSON, RYAN KEITH (LPC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:KEITH
Last Name:WATSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MEDI PARK DR STE 2058
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2109
Mailing Address - Country:US
Mailing Address - Phone:806-418-8900
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR STE 2058
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2109
Practice Address - Country:US
Practice Address - Phone:806-418-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61896101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1942823-01Medicaid