Provider Demographics
NPI:1780257915
Name:GRANT, WATTA MARTHA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:WATTA
Middle Name:MARTHA
Last Name:GRANT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:WATTA
Other - Middle Name:
Other - Last Name:KENNEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2709
Mailing Address - Country:US
Mailing Address - Phone:903-234-0776
Mailing Address - Fax:
Practice Address - Street 1:3150 CLARKSVILLE ST STE 300
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-8082
Practice Address - Country:US
Practice Address - Phone:903-785-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-24
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1040939363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health