Healthcare Provider Details

I. General information

NPI: 1407432115
Provider Name (Legal Business Name): DANNA YVONNE BAILEY-WATTS LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANNA YVONNE THERIAULT

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 TENAHA ST
CENTER TX
75935-3036
US

IV. Provider business mailing address

1110 TENAHA ST
CENTER TX
75935-3036
US

V. Phone/Fax

Practice location:
  • Phone: 936-598-6608
  • Fax: 936-598-6618
Mailing address:
  • Phone: 936-598-6608
  • Fax: 936-598-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12745
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: