Healthcare Provider Details

I. General information

NPI: 1891223723
Provider Name (Legal Business Name): ANTHONY WATTS LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 CATTAIL RD
CHILLICOTHEE OH
45601-9404
US

IV. Provider business mailing address

11 GRAHAM DR
ATHENS OH
45701-1430
US

V. Phone/Fax

Practice location:
  • Phone: 740-594-6807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600284-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: