Provider Demographics
NPI:1861589368
Name:WATT, SUZAN ALLEN (MED)
Entity type:Individual
Prefix:MRS
First Name:SUZAN
Middle Name:ALLEN
Last Name:WATT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-9514
Mailing Address - Country:US
Mailing Address - Phone:803-240-5460
Mailing Address - Fax:
Practice Address - Street 1:430 CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-9514
Practice Address - Country:US
Practice Address - Phone:803-240-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1976101YP2500X
SC2482101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3335OtherMEDICARE