Provider Demographics
NPI:1861165631
Name:WATSON, LYBRA RENAE (LISW)
Entity type:Individual
Prefix:MS
First Name:LYBRA
Middle Name:RENAE
Last Name:WATSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 BROADWAY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-7379
Mailing Address - Country:US
Mailing Address - Phone:614-419-9751
Mailing Address - Fax:
Practice Address - Street 1:5936 GLENWAY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2009
Practice Address - Country:US
Practice Address - Phone:513-922-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21028111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462231Medicaid