Provider Demographics
NPI:1245885417
Name:WATKINS, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
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 1:2504 BROWNING ROAD 520
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-6022
Mailing Address - Country:US
Mailing Address - Phone:662-453-6211
Mailing Address - Fax:
Practice Address - Street 1:250 OSCAR ST
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-4116
Practice Address - Country:US
Practice Address - Phone:662-756-4698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4719101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health