Provider Demographics
NPI:1982446431
Name:WATSON, THERESA (LPT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S WESTWOOD ST SPC 159
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-7709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 CAMINO DEL REMEDIO
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1332
Practice Address - Country:US
Practice Address - Phone:805-465-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30688167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician