Provider Demographics
NPI:1417422460
Name:MOULTRY-WATSON, MONIQUE MESHAUN (LISW-CP)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MESHAUN
Last Name:MOULTRY-WATSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PARK ST STE 101-1313
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2011
Mailing Address - Country:US
Mailing Address - Phone:933-803-9313
Mailing Address - Fax:
Practice Address - Street 1:2000 PARK ST STE 101-1313
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2011
Practice Address - Country:US
Practice Address - Phone:803-996-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16988104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker