Provider Demographics
NPI:1194094268
Name:R GLEN WATSON, LCSW INC.
Entity type:Organization
Organization Name:R GLEN WATSON, LCSW INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-479-0411
Mailing Address - Street 1:250 CUSHMAN ST
Mailing Address - Street 2:SUITE 3-E
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4640
Mailing Address - Country:US
Mailing Address - Phone:907-479-0411
Mailing Address - Fax:
Practice Address - Street 1:250 CUSHMAN ST
Practice Address - Street 2:SUITE 3-E
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4640
Practice Address - Country:US
Practice Address - Phone:907-479-0411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty