Provider Demographics
NPI:1285485086
Name:WATTERSON, KENMAR (CPRS)
Entity type:Individual
Prefix:
First Name:KENMAR
Middle Name:
Last Name:WATTERSON
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 CHELSEA SQUARE AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4446
Mailing Address - Country:US
Mailing Address - Phone:513-462-1079
Mailing Address - Fax:
Practice Address - Street 1:4145 CHELSEA SQUARE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-4454
Practice Address - Country:US
Practice Address - Phone:513-462-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004566101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)