Healthcare Provider Details

I. General information

NPI: 1356259170
Provider Name (Legal Business Name): WATTERS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 HAMPTON PKWY APT G1
EVANSTON IL
60201-1637
US

IV. Provider business mailing address

2317 N CLARK ST APT 408
CHICAGO IL
60614-8483
US

V. Phone/Fax

Practice location:
  • Phone: 214-535-8529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RYAN WATTERS
Title or Position: FOUNDER / THERAPIST
Credential: LCSW, CADC
Phone: 214-535-8529