Provider Demographics
NPI:1962618710
Name:WATSON, LARRY GORDON (EDS)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:GORDON
Last Name:WATSON
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 GROTON DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-1219
Mailing Address - Country:US
Mailing Address - Phone:330-650-2243
Mailing Address - Fax:
Practice Address - Street 1:1755 MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5296
Practice Address - Country:US
Practice Address - Phone:330-836-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 330103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool