Provider Demographics
NPI:1497043053
Name:WATKINS, KRISTY
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:WATKINS
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 1:4211 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3110
Mailing Address - Country:US
Mailing Address - Phone:248-217-5991
Mailing Address - Fax:
Practice Address - Street 1:20303 KELLY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48225-1206
Practice Address - Country:US
Practice Address - Phone:313-550-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010932891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical