Basic Information
| Provider Information | |||||||||
| NPI: | 1164845616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 4124 1/2 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921041689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058132833 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2014 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS28380 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.