Provider Demographics
NPI:1770211658
Name:WATSON, DOUGLAS LEE (PMHNP)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:WATSON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:L
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, PMHNP-BC, RN
Mailing Address - Street 1:2855 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2691
Mailing Address - Country:US
Mailing Address - Phone:502-265-5866
Mailing Address - Fax:765-308-5660
Practice Address - Street 1:2855 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2691
Practice Address - Country:US
Practice Address - Phone:502-265-5866
Practice Address - Fax:765-308-5660
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1030062854163WC0200X
IN71013479A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300010664Medicaid
KY7100535740Medicaid
ININ3604OtherMEDICARE
KYK258180OtherMEDICARE