Provider Demographics
NPI:1447359757
Name:WATTS, ANDREA LASHUN (C5643)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LASHUN
Last Name:WATTS
Suffix:
Gender:F
Credentials:C5643
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 GRANT FERRY RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-665-4162
Mailing Address - Fax:855-830-3484
Practice Address - Street 1:1911 MISSION 66 STE B
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3762
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:855-830-3484
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM5643104100000X
MSC56431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker