Provider Demographics
NPI:1215264825
Name:WATTS, GANNON JOE (LPC, LAC, NCC)
Entity type:Individual
Prefix:
First Name:GANNON
Middle Name:JOE
Last Name:WATTS
Suffix:
Gender:M
Credentials:LPC, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9685
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70562-9685
Mailing Address - Country:US
Mailing Address - Phone:337-251-6503
Mailing Address - Fax:337-367-7850
Practice Address - Street 1:203 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3795
Practice Address - Country:US
Practice Address - Phone:337-251-6503
Practice Address - Fax:337-367-7850
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1273101YA0400X
LA3771101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)