Provider Demographics
NPI:1386987832
Name:WATKINS, MARK ANTHONY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:WATKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N PRAIRIE AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4505
Mailing Address - Country:US
Mailing Address - Phone:310-673-4117
Mailing Address - Fax:
Practice Address - Street 1:323 N PRAIRIE AVE STE 315
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4505
Practice Address - Country:US
Practice Address - Phone:310-673-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)