Provider Demographics
NPI:1225081409
Name:WATJEN, AUDREY ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:ANNE
Last Name:WATJEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:A
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2013 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2528
Mailing Address - Country:US
Mailing Address - Phone:603-627-2702
Mailing Address - Fax:603-627-3643
Practice Address - Street 1:2013 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2528
Practice Address - Country:US
Practice Address - Phone:603-627-2702
Practice Address - Fax:603-627-3643
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLICSW82104100000X
TN56041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE6592Medicare ID - Type Unspecified