Provider Demographics
NPI:1316300429
Name:WATKINS, MISTY DAWN (MSBS)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:DAWN
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MSBS
Other - Prefix:MS
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2414 NW NORMAN CIR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1417
Mailing Address - Country:US
Mailing Address - Phone:580-284-8729
Mailing Address - Fax:
Practice Address - Street 1:2414 NW NORMAN CIR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1417
Practice Address - Country:US
Practice Address - Phone:580-284-8729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional