Healthcare Provider Details

I. General information

NPI: 1700170537
Provider Name (Legal Business Name): HEIDI WATSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 NW STEWART PKWY
ROSEBURG OR
97471-1281
US

IV. Provider business mailing address

272 NW MEDICAL LOOP SUITE E
ROSEBURG OR
97471-5597
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax: 541-440-3508
Mailing address:
  • Phone: 541-440-3532
  • Fax: 541-440-3508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2847
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: