Provider Demographics
NPI:1699418848
Name:WATTS, RUSSELL EDWARD (QMHA - 1)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EDWARD
Last Name:WATTS
Suffix:
Gender:M
Credentials:QMHA - 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5140
Mailing Address - Country:US
Mailing Address - Phone:541-426-4524
Mailing Address - Fax:
Practice Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-682-7625
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3380171M00000X
175T00000X
OR23-QMHA-1-004015171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist