Provider Demographics
NPI:1447586375
Name:WATSON, MICHELE GREEN (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:GREEN
Last Name:WATSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:29520 CANVASBACK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7124
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:410-822-5569
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MDLGP3628101YM0800X
MDLC4641101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500300Medicaid
MD609550002Medicaid
MD609550001Medicaid
MD609500303Medicaid
MD609550004Medicaid