Healthcare Provider Details

I. General information

NPI: 1407959596
Provider Name (Legal Business Name): P. MARK WATTS DMIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 ELM ST MANNING HOUSE
MANCHESTER NH
03104-2528
US

IV. Provider business mailing address

2013 ELM ST MANNING HOUSE
MANCHESTER NH
03104-2528
US

V. Phone/Fax

Practice location:
  • Phone: 603-627-2702
  • Fax: 603-627-3643
Mailing address:
  • Phone: 603-627-2702
  • Fax: 603-627-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number35
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: