Provider Demographics
NPI:1770069981
Name:WATTS, VANESSA BLAIR (PHD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:BLAIR
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 1:1740 COMBE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5094
Mailing Address - Country:US
Mailing Address - Phone:801-621-7064
Mailing Address - Fax:
Practice Address - Street 1:1740 COMBE RD STE 5
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5094
Practice Address - Country:US
Practice Address - Phone:801-621-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100711042501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical