Provider Demographics
NPI:1053755850
Name:WATSON, SHANTELL KASANDRA DEAN
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:KASANDRA DEAN
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CABINET ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01129-1646
Mailing Address - Country:US
Mailing Address - Phone:413-686-1528
Mailing Address - Fax:
Practice Address - Street 1:319 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3968
Practice Address - Country:US
Practice Address - Phone:413-540-1234
Practice Address - Fax:413-538-5169
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor