Healthcare Provider Details

I. General information

NPI: 1497231005
Provider Name (Legal Business Name): KEAHNNA MAE WATTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 WABASH ST UNIT 10-102
FORT COLLINS CO
80526-6811
US

IV. Provider business mailing address

1020 WABASH ST UNIT 10-102
FORT COLLINS CO
80526-6811
US

V. Phone/Fax

Practice location:
  • Phone: 913-302-1990
  • Fax:
Mailing address:
  • Phone: 913-302-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68223
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: