Provider Demographics
NPI:1770903866
Name:WATSON, WANDA (LGSW)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 DUNBAR AVE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-3121
Mailing Address - Country:US
Mailing Address - Phone:304-766-7336
Mailing Address - Fax:304-766-7334
Practice Address - Street 1:5600 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2146
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-399-1177
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944091104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
WV0005355002Medicaid