Provider Demographics
NPI:1831852169
Name:WATSON, DONALD RAY II (MA)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RAY
Last Name:WATSON
Suffix:II
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 N RIDGEWAY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5727
Mailing Address - Country:US
Mailing Address - Phone:773-242-7709
Mailing Address - Fax:
Practice Address - Street 1:5235 N CLARK ST FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2122
Practice Address - Country:US
Practice Address - Phone:312-298-9846
Practice Address - Fax:312-254-2138
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001504106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty