Provider Demographics
NPI:1811038961
Name:WATSON, STEPHANIE M (MAMFC, LPCI)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:WATSON
Suffix:
Gender:F
Credentials:MAMFC, LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7770
Mailing Address - Country:US
Mailing Address - Phone:601-992-7071
Mailing Address - Fax:
Practice Address - Street 1:5611 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-8929
Practice Address - Country:US
Practice Address - Phone:601-939-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4781101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health