Provider Demographics
NPI:1659555183
Name:WATKINS, PERRY TANIS (MPA)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:TANIS
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MPA
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 217125
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28221-0125
Mailing Address - Country:US
Mailing Address - Phone:704-506-6888
Mailing Address - Fax:704-378-0363
Practice Address - Street 1:6120 CARRIAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3253
Practice Address - Country:US
Practice Address - Phone:704-506-6888
Practice Address - Fax:704-378-0363
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-081-074322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children