Healthcare Provider Details

I. General information

NPI: 1528235975
Provider Name (Legal Business Name): MARIANNE WATTS LPC, LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3864 N 27TH AVE
PHOENIX AZ
85017-4703
US

IV. Provider business mailing address

3003 N CENTRAL AVE SUITE 200
PHOENIX AZ
85012-2902
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-995-8503
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10608
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0612
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12510
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: