Provider Demographics
NPI:1457700312
Name:WATSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:304 OLSON DR STE 115-704
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-2976
Mailing Address - Country:US
Mailing Address - Phone:887-258-0288
Mailing Address - Fax:
Practice Address - Street 1:304 OLSON DR STE 115
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-2979
Practice Address - Country:US
Practice Address - Phone:707-631-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1126101YA0400X
WA609925471041C0700X
HI44871041C0700X
CO099258851041C0700X
IA775071041C0700X
NE18241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)