Provider Demographics
NPI:1689233538
Name:WATT, THERESSA (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:THERESSA
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:THERESSA
Other - Middle Name:
Other - Last Name:DURENBERGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LMFT
Mailing Address - Street 1:1154 GRAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1154 GRAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2628
Practice Address - Country:US
Practice Address - Phone:612-567-4842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3553106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist