Provider Demographics
NPI:1356871305
Name:WATTA, JUDITH (LCSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:WATTA
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:PO BOX 806054
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-6054
Mailing Address - Country:US
Mailing Address - Phone:571-449-7837
Mailing Address - Fax:571-449-7837
Practice Address - Street 1:21 N BROAD ST STE E # 10104
Practice Address - Street 2:
Practice Address - City:LURAY
Practice Address - State:VA
Practice Address - Zip Code:22835-1162
Practice Address - Country:US
Practice Address - Phone:571-449-7837
Practice Address - Fax:571-449-7837
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
09040098961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical