Provider Demographics
NPI:1023001898
Name:WATKINS, LORI ANN (MED CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:ANN
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MED CCC SLP
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:MAHAFFY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CCC SLP
Mailing Address - Street 1:25 ARBOR CLUB DR UNIT 106
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2673
Mailing Address - Country:US
Mailing Address - Phone:904-534-3952
Mailing Address - Fax:
Practice Address - Street 1:25 ARBOR CLUB DR UNIT 106
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2673
Practice Address - Country:US
Practice Address - Phone:904-534-3952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887482400Medicaid