Healthcare Provider Details

I. General information

NPI: 1720031008
Provider Name (Legal Business Name): KEITH D WATTS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 NAAB RD 103
INDIANAPOLIS IN
46260-5925
US

IV. Provider business mailing address

8330 NAAB RD 103
INDIANAPOLIS IN
46260-5925
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-1600
  • Fax: 317-988-1617
Mailing address:
  • Phone: 317-988-1600
  • Fax: 317-988-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003668A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: