Basic Information
| Provider Information | |||||||||
| NPI: | 1033541115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MICAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 S HUBBARDS LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729210349 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 ROCKWOOD LN | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064365761 | ||||||||
| FaxNumber: | 6064350817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2013 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 246778 | KY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.