Provider Demographics
NPI:1699048728
Name:WATSON, EDWIN SELMAN (PHD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:SELMAN
Last Name:WATSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2850
Practice Address - Country:US
Practice Address - Phone:803-256-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC340103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical