Provider Demographics
NPI:1568512358
Name:WILLETT, MONIQUE MICHELE (LICSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MICHELE
Last Name:WILLETT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 WATERMAN ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3109
Mailing Address - Country:US
Mailing Address - Phone:248-229-1819
Mailing Address - Fax:
Practice Address - Street 1:530 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5762
Practice Address - Country:US
Practice Address - Phone:401-274-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISWO19761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid