Provider Demographics
NPI:1740725167
Name:WATSON, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
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 1:11100 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-1943
Mailing Address - Country:US
Mailing Address - Phone:216-664-2904
Mailing Address - Fax:216-420-7744
Practice Address - Street 1:11100 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-1943
Practice Address - Country:US
Practice Address - Phone:216-664-2904
Practice Address - Fax:216-420-7744
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH933686101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH933686Medicaid
OH933686OtherSELF-PAY