Provider Demographics
NPI:1801136361
Name:NICK WATTERS, PSYD PLC
Entity type:Organization
Organization Name:NICK WATTERS, PSYD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:270-401-4107
Mailing Address - Street 1:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6278
Mailing Address - Country:US
Mailing Address - Phone:270-401-4107
Mailing Address - Fax:270-209-0872
Practice Address - Street 1:240 W DIXIE AVE
Practice Address - Street 2:SUITE 5-B
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1586
Practice Address - Country:US
Practice Address - Phone:270-401-4107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY30605018Medicaid