Provider Demographics
NPI:1265620330
Name:WATSON, KIM DAVIS (MED)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:DAVIS
Last Name:WATSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 WILSHIRE BLVD N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-1856
Mailing Address - Country:US
Mailing Address - Phone:252-243-5793
Mailing Address - Fax:252-243-7486
Practice Address - Street 1:1716 WILSHIRE BLVD N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-1856
Practice Address - Country:US
Practice Address - Phone:252-243-5793
Practice Address - Fax:252-243-7486
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-14
Last Update Date:2007-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9077101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor