Healthcare Provider Details

I. General information

NPI: 1669426771
Provider Name (Legal Business Name): EDMOND B WATTS JR. LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VETERANS AVE
BECKLEY WV
25801-6444
US

IV. Provider business mailing address

307 WYOMING AVE
BECKLEY WV
25801-3434
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-2121
  • Fax: 304-255-2431
Mailing address:
  • Phone: 304-252-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00939215
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: