Healthcare Provider Details

I. General information

NPI: 1770211658
Provider Name (Legal Business Name): DOUGLAS LEE WATSON PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DOUG L WATSON APRN, PMHNP-BC, RN

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 CHARLESTOWN RD
NEW ALBANY IN
47150-2691
US

IV. Provider business mailing address

2855 CHARLESTOWN RD
NEW ALBANY IN
47150-2691
US

V. Phone/Fax

Practice location:
  • Phone: 502-265-5866
  • Fax: 765-308-5660
Mailing address:
  • Phone: 502-265-5866
  • Fax: 765-308-5660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1030062854
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71013479A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: