Provider Demographics
NPI:1396890620
Name:THE WATKINS HOME
Entity type:Organization
Organization Name:THE WATKINS HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-535-5533
Mailing Address - Street 1:15372 W ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8980
Mailing Address - Country:US
Mailing Address - Phone:623-535-5533
Mailing Address - Fax:623-535-6666
Practice Address - Street 1:15372 W ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8980
Practice Address - Country:US
Practice Address - Phone:623-535-5533
Practice Address - Fax:623-535-6666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4267302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH2622OtherOBHL LICENSE
AZ941147Medicaid
AZBH3584OtherOFFICE OF BEHAVIORAL HEALTH LICENSE NUMBER