Healthcare Provider Details

I. General information

NPI: 1144051350
Provider Name (Legal Business Name): TYEISHA MICHELLE WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 S DUPONT HWY
DOVER DE
19901-4468
US

IV. Provider business mailing address

911 S DUPONT HWY
DOVER DE
19901-4468
US

V. Phone/Fax

Practice location:
  • Phone: 302-570-2980
  • Fax:
Mailing address:
  • Phone: 302-570-2980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberQ3-0011345
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: