Healthcare Provider Details

I. General information

NPI: 1891179115
Provider Name (Legal Business Name): CORY D WATSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CORY WATSON LCSW

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SIJEN AVE
WHITEMAN AFB MO
65305-1269
US

IV. Provider business mailing address

331 SIJEN AVE BLDG 2032
WHITEMAN AFB MO
65305-1269
US

V. Phone/Fax

Practice location:
  • Phone: 660-687-4341
  • Fax:
Mailing address:
  • Phone: 660-687-7332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2015016528
License Number StateMO

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: