Provider Demographics
NPI:1003382979
Name:WATTS, SARAN CHARISSE
Entity Type:Individual
Prefix:MS
First Name:SARAN
Middle Name:CHARISSE
Last Name:WATTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31160 WILDWOOD ST APT 5210
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31101 ALLEN RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195
Practice Address - Country:US
Practice Address - Phone:616-818-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty