Provider Demographics
NPI:1649427154
Name:LA PLACE-WATTS, MICHELLE LOREN
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LOREN
Last Name:LA PLACE-WATTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 68TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2188
Mailing Address - Country:US
Mailing Address - Phone:510-715-6667
Mailing Address - Fax:
Practice Address - Street 1:3527 68TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2188
Practice Address - Country:US
Practice Address - Phone:510-715-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA1002961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health