Provider Demographics
NPI:1144091893
Name:WATSON, LAVON JANEEN
Entity type:Individual
Prefix:
First Name:LAVON
Middle Name:JANEEN
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 E 105TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3023
Mailing Address - Country:US
Mailing Address - Phone:678-857-6224
Mailing Address - Fax:
Practice Address - Street 1:731 E 105TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3023
Practice Address - Country:US
Practice Address - Phone:678-857-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician