Healthcare Provider Details

I. General information

NPI: 1902388234
Provider Name (Legal Business Name): MICHELE GRANVILLE WATSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MARKET ST
HARTFORD CT
06120-2901
US

IV. Provider business mailing address

106 BARRY RD
MANCHESTER CT
06042-3326
US

V. Phone/Fax

Practice location:
  • Phone: 860-761-7908
  • Fax:
Mailing address:
  • Phone: 860-287-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4845
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number012160
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: