Provider Demographics
NPI:1790704369
Name:WATT DENNIS, TANYA (MSW CSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WATT DENNIS
Suffix:
Gender:F
Credentials:MSW CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2718 E LAFAYETTE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3963
Mailing Address - Country:US
Mailing Address - Phone:248-559-1763
Mailing Address - Fax:
Practice Address - Street 1:2718 E LAFAYETTE ST APT 204
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3963
Practice Address - Country:US
Practice Address - Phone:248-559-1763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801068072103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6801068072OtherSTATE LIC