=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770069981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANESSA BLAIR WATTS PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2018
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 COMBE RD STE 5
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-621-7064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 COMBE RD STE 5
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-621-7064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 100711042501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------