Provider Demographics
NPI:1669609764
Name:WATSON, LISA MARIE (MHPP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WILBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1425 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1431
Practice Address - Country:US
Practice Address - Phone:870-886-5303
Practice Address - Fax:870-886-7002
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169348795Medicaid