Healthcare Provider Details

I. General information

NPI: 1508701616
Provider Name (Legal Business Name): 479 WATT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 CARRIE AVE
CINCINNATI OH
45211-3412
US

IV. Provider business mailing address

3970 CARRIE AVE
CINCINNATI OH
45211-3412
US

V. Phone/Fax

Practice location:
  • Phone: 513-549-3095
  • Fax:
Mailing address:
  • Phone: 513-549-3095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KENMAR YONDRA WATTERSON
Title or Position: PEER SUPPORT
Credential: CPRS
Phone: 513-549-3095