Provider Demographics
NPI:1104697440
Name:WATSON, SHIMARA
Entity type:Individual
Prefix:
First Name:SHIMARA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 FELLOWSHIP RD, EAST GATE CENTER
Mailing Address - Street 2:200
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1448
Mailing Address - Country:US
Mailing Address - Phone:347-458-5494
Mailing Address - Fax:
Practice Address - Street 1:76 SISTERS FARMSTEAD DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1448
Practice Address - Country:US
Practice Address - Phone:347-458-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ320900000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities