Healthcare Provider Details

I. General information

NPI: 1447359757
Provider Name (Legal Business Name): ANDREA LASHUN WATTS C5643
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MISSION 66 STE B
VICKSBURG MS
39180-3762
US

IV. Provider business mailing address

557 GRANT FERRY RD
BRANDON MS
39047
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 855-830-3484
Mailing address:
  • Phone: 601-665-4162
  • Fax: 855-830-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM5643
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC5643
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: