=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578212627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIEL E WATSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2022
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2399 E WALTON BLVD
-----------------------------------------------------
City | AUBURN HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48326-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-977-6510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23460 CAYUGA AVE
-----------------------------------------------------
City | HAZEL PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48030-2727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-765-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6851110128
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801118981
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------