Provider Demographics
NPI:1902388234
Name:WATSON, MICHELE GRANVILLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:GRANVILLE
Last Name:WATSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BARRY RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3326
Mailing Address - Country:US
Mailing Address - Phone:860-287-0384
Mailing Address - Fax:
Practice Address - Street 1:330 MARKET ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120-2901
Practice Address - Country:US
Practice Address - Phone:860-761-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0121601041C0700X
CT4845104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program