Provider Demographics
NPI:1619444007
Name:WATERMAN, MICHELL NICOLE (MED)
Entity Type:Individual
Prefix:MS
First Name:MICHELL
Middle Name:NICOLE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 LOVE LN FL 3
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1615
Mailing Address - Country:US
Mailing Address - Phone:860-778-4866
Mailing Address - Fax:
Practice Address - Street 1:95 FRANK B MURRAY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1106
Practice Address - Country:US
Practice Address - Phone:413-285-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT086758642OtherDEPARTMENT OF MOTOR VEHICLES