Provider Demographics
NPI:1093224552
Name:WATKINS, SHATAYLA CASONDA (QMHS)
Entity Type:Individual
Prefix:
First Name:SHATAYLA
Middle Name:CASONDA
Last Name:WATKINS
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 NORTHLAND DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3440
Mailing Address - Country:US
Mailing Address - Phone:330-725-9195
Mailing Address - Fax:330-725-9187
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:330-725-9187
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst