Healthcare Provider Details

I. General information

NPI: 1386460327
Provider Name (Legal Business Name): KASSEY LATARA WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 MAHONING AVE NW
WARREN OH
44483-4605
US

IV. Provider business mailing address

2101 OAKDALE DR NW
WARREN OH
44485-1439
US

V. Phone/Fax

Practice location:
  • Phone: 330-395-9563
  • Fax:
Mailing address:
  • Phone: 330-984-6683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: