Provider Demographics
NPI:1336560325
Name:WATTS, MALIA
Entity type:Individual
Prefix:MS
First Name:MALIA
Middle Name:
Last Name:WATTS
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 1:1122 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3347
Mailing Address - Country:US
Mailing Address - Phone:501-328-3274
Mailing Address - Fax:
Practice Address - Street 1:1122 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3347
Practice Address - Country:US
Practice Address - Phone:501-328-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1704198101YM0800X
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199570795Medicaid