Provider Demographics
NPI:1720422371
Name:WATTS, TYRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TYRA
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 LE CHATEAU CV
Mailing Address - Street 2:OPTIONAL
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-0267
Mailing Address - Country:US
Mailing Address - Phone:901-921-6566
Mailing Address - Fax:888-551-0262
Practice Address - Street 1:5080 LE CHATEAU COVE
Practice Address - Street 2:OPTIONAL
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-0267
Practice Address - Country:US
Practice Address - Phone:901-921-6566
Practice Address - Fax:888-551-0262
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 225C00000X
TN5879101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor