Provider Demographics
NPI:1669426771
Name:WATTS, EDMOND B JR (LICSW)
Entity type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:B
Last Name:WATTS
Suffix:JR
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3434
Mailing Address - Country:US
Mailing Address - Phone:304-252-1997
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:304-255-2431
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009392151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical