Provider Demographics
NPI:1104208669
Name:WATTERSON, PAMELA (LCSW)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WATTERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 ROCKFORD CT
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3207
Mailing Address - Country:US
Mailing Address - Phone:765-453-4500
Mailing Address - Fax:765-453-4525
Practice Address - Street 1:1531 ROCKFORD CT
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3207
Practice Address - Country:US
Practice Address - Phone:765-453-4500
Practice Address - Fax:765-453-4525
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000411A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34000411AOtherLICENSE NUMBER
IN201191370AMedicaid
ININ1699Medicare PIN