Healthcare Provider Details

I. General information

NPI: 1225081409
Provider Name (Legal Business Name): AUDREY ANNE WATJEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDREY A MOSES

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 ELM ST
MANCHESTER NH
03104-2528
US

IV. Provider business mailing address

2013 ELM ST
MANCHESTER NH
03104-2528
US

V. Phone/Fax

Practice location:
  • Phone: 603-627-2702
  • Fax: 603-627-3643
Mailing address:
  • Phone: 603-627-2702
  • Fax: 603-627-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLICSW82
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5604
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: