=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659674612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA WILKERSON WATSON LMFTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2010
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9925 KATY FRWY STE 420
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-443-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 STONELEIGH DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-6924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-443-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 201632
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------