Provider Demographics
NPI:1962971978
Name:WATSON, GRETCHEN J (MSW MFTIT)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:J
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSW MFTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:
Practice Address - Street 1:3200 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3252
Practice Address - Country:US
Practice Address - Phone:262-444-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
WI106H00000X
WI659-228106H00000X
WI1397-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-0806174Medicaid