1104028133 NPI number — VIRGINIA WATTS M.ED., LCPC

Table of content: VIRGINIA WATTS M.ED., LCPC (NPI 1104028133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104028133 NPI number — VIRGINIA WATTS M.ED., LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATTS
Provider First Name:
VIRGINIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED., LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104028133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1377
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELGRADE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59714-1377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-388-7174
Provider Business Mailing Address Fax Number:
406-388-4958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 VILLAGE DR STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELGRADE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59714-9618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-388-7174
Provider Business Practice Location Address Fax Number:
406-388-4958
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  597 LCPC , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0254796 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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