Healthcare Provider Details

I. General information

NPI: 1225193089
Provider Name (Legal Business Name): NICOLE DANIELLE WATTS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

IV. Provider business mailing address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

V. Phone/Fax

Practice location:
  • Phone: 323-380-7590
  • Fax:
Mailing address:
  • Phone: 323-380-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005250
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: