Provider Demographics
NPI:1891179115
Name:WATSON, CORY D (LCSW)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:D
Last Name:WATSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:CORY
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:331 SIJEN AVE BLDG 2032
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-7332
Mailing Address - Fax:
Practice Address - Street 1:331 SIJEN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150165281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical