Provider Demographics
NPI:1285262287
Name:WATSON, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
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 1:1528 UNION RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2200
Mailing Address - Country:US
Mailing Address - Phone:704-864-1477
Mailing Address - Fax:704-396-7524
Practice Address - Street 1:3801 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4615
Practice Address - Country:US
Practice Address - Phone:704-864-1477
Practice Address - Fax:704-396-7524
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490197881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical