Provider Demographics
NPI:1386315349
Name:WATTS, TAREVA (LLMSW)
Entity type:Individual
Prefix:
First Name:TAREVA
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 MALL CT # 247
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-5200
Mailing Address - Country:US
Mailing Address - Phone:517-803-9326
Mailing Address - Fax:
Practice Address - Street 1:4211 OKEMOS RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3287
Practice Address - Country:US
Practice Address - Phone:517-803-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851107896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional