Provider Demographics
NPI:1366920704
Name:WATSON, MICHAEL JOHN (CADC 1)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:WATSON
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 NW F ST # 87
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2012
Mailing Address - Country:US
Mailing Address - Phone:541-450-7204
Mailing Address - Fax:541-479-2370
Practice Address - Street 1:720 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1524
Practice Address - Country:US
Practice Address - Phone:541-237-5062
Practice Address - Fax:541-955-7499
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000002886175T00000X
247000000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information