MEDICARE: EVA JANE WATTS MSW,LCSW,CSAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2060	NC
2	101YM0800X	Mental Health Counselor	C005802	NC
3	104100000X	Social Worker	C005802	NC
4	1041C0700X	Clinical Social Worker	C005802	NC
5	251S00000X	Community/Behavioral Health Agency	C005802	NC

General Provider Information

NPI Number	:	1619164217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA JANE WATTS MSW,LCSW,CSAC

Provider Business Mailing Address
First Line	:	4715 PENNOAK RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-4029
Country	:	US
Telephone Number	:	336-638-8136
Fax Number	:

Provider Business Practice Location Address
First Line	:	4715 PENNOAK RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-4029
Country	:	US
Telephone Number	:	336-638-8136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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