Provider Demographics
NPI:1306130372
Name:WATSON, SHANDA LEANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:LEANN
Last Name:WATSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E MAIN ST
Mailing Address - Street 2:PO BOX 194
Mailing Address - City:COLE CAMP
Mailing Address - State:MO
Mailing Address - Zip Code:65325-1240
Mailing Address - Country:US
Mailing Address - Phone:660-668-0155
Mailing Address - Fax:660-668-0156
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLE CAMP
Practice Address - State:MO
Practice Address - Zip Code:65325-1240
Practice Address - Country:US
Practice Address - Phone:660-668-0155
Practice Address - Fax:660-668-0156
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012003674103K00000X, 1041C0700X, 104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool