Healthcare Provider Details

I. General information

NPI: 1992920938
Provider Name (Legal Business Name): ISAAC GORDON WATTS M.A., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 209E
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

233 FULTON ST E STE 209E
GRAND RAPIDS MI
49503-3200
US

V. Phone/Fax

Practice location:
  • Phone: 616-279-9978
  • Fax: 616-724-4331
Mailing address:
  • Phone: 616-279-9978
  • Fax: 616-724-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009315
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: