Healthcare Provider Details

I. General information

NPI: 1477860849
Provider Name (Legal Business Name): CONNIE A WATTS MS, LCMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E 2ND AVE
MEDICINE LODGE KS
67104-1306
US

IV. Provider business mailing address

205 S WALNUT ST
MEDICINE LODGE KS
67104-1418
US

V. Phone/Fax

Practice location:
  • Phone: 620-213-1016
  • Fax:
Mailing address:
  • Phone: 620-213-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number288
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: