Healthcare Provider Details

I. General information

NPI: 1679487193
Provider Name (Legal Business Name): PATRICIA DENISE JOHNSON WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 STATE ST
EAST SAINT LOUIS IL
62205-1356
US

IV. Provider business mailing address

560 WREN DR
FLORISSANT MO
63031-2156
US

V. Phone/Fax

Practice location:
  • Phone: 618-646-3700
  • Fax:
Mailing address:
  • Phone: 678-755-5775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: