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General NPI Number Information
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NPI Number | 1063468817
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Entity Type | Individual
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Provider Name | NICHOLAS WATTERS PSYD
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Gender | Male
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Dates
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Enumeration Date | 05/25/2006
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Last Update Date | 09/17/2024
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Provider Practice Location Address
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Address Line | 1002 N MULBERRY ST STE 100
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2037
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Country | US
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Telephone | 270-401-4107
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Fax | 270-209-0872
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Provider Business Mailing Address
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Address Line | 216 LA FONTENAY CT
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City | LOUISVILLE
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State | KY
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Zip | 40223-3002
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Country | US
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Telephone | 270-401-4107
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Fax | 270-209-0872
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1492
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License Number State | KY
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