Provider Demographics
NPI:1386925576
Name:WATSON, WENDY (PPC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 FORT SANDERS RD
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-8308
Mailing Address - Country:US
Mailing Address - Phone:307-745-8997
Mailing Address - Fax:
Practice Address - Street 1:4989 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-9548
Practice Address - Country:US
Practice Address - Phone:307-774-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY556101Y00000X
WYLPC - 1321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY556OtherSTATE LICENSE
WYLPC - 1321OtherSTATE LICENSE