Provider Demographics
NPI:1932636925
Name:WATKINS, LEISA (LMFT)
Entity Type:Individual
Prefix:
First Name:LEISA
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2634
Mailing Address - Country:US
Mailing Address - Phone:208-524-3733
Mailing Address - Fax:
Practice Address - Street 1:548 LOMAX ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2634
Practice Address - Country:US
Practice Address - Phone:208-552-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-7510106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist