Provider Demographics
NPI:1194033100
Name:WATKINS, TIMOTHY W (LCSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:WATKINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 EAGLE ST
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052-8705
Practice Address - Country:US
Practice Address - Phone:505-465-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07371104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB8961Medicaid