Provider Demographics
NPI:1760658223
Name:WATTERS, COLLEEN FASSETT (LCSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:FASSETT
Last Name:WATTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:FASSETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9455 W WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3559
Mailing Address - Country:US
Mailing Address - Phone:414-257-7222
Mailing Address - Fax:
Practice Address - Street 1:9455 W WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3559
Practice Address - Country:US
Practice Address - Phone:414-257-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7047-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7047-123OtherLCSW