Healthcare Provider Details

I. General information

NPI: 1639425747
Provider Name (Legal Business Name): GARY W WATSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SPAULDING AVE STE D.
ADA MI
49301
US

IV. Provider business mailing address

975 SPAULDING AVE. STE D.
ADA MI
49301
US

V. Phone/Fax

Practice location:
  • Phone: 616-914-9874
  • Fax: 616-825-6007
Mailing address:
  • Phone: 616-914-9874
  • Fax: 616-825-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088218
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: