Healthcare Provider Details

I. General information

NPI: 1598629198
Provider Name (Legal Business Name): GRANADA REBECCA WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 BRITT DR
LAWRENCEVILLE GA
30046-9472
US

IV. Provider business mailing address

256 BRITT DR
LAWRENCEVILLE GA
30046-9472
US

V. Phone/Fax

Practice location:
  • Phone: 770-367-2406
  • Fax:
Mailing address:
  • Phone: 770-367-2406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC010806
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: