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General NPI Number Information
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NPI Number | 1194094268
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Entity Type | Organization
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Legal Business Name | R GLEN WATSON, LCSW INC.
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Dates
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Enumeration Date | 12/20/2011
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Last Update Date | 12/20/2011
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Provider Practice Location Address
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Address Line | 250 CUSHMAN ST SUITE 3-E
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City | FAIRBANKS
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State | AK
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Zip | 99701-4640
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Country | US
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Telephone | 907-479-0411
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Fax |
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Provider Business Mailing Address
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Address Line | 250 CUSHMAN ST SUITE 3-E
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City | FAIRBANKS
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State | AK
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Zip | 99701-4640
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Country | US
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Telephone | 907-479-0411
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROY GLEN WATSON
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Credential |
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Telephone | 907-479-0411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 161
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License Number State | AK
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