1861792202 NPI number — MR. ALFONZO WATKINS MSE, LPC

Table of content: MR. ALFONZO WATKINS MSE, LPC (NPI 1861792202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861792202 NPI number — MR. ALFONZO WATKINS MSE, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
ALFONZO
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSE, LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861792202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 E AUER AVE SUITE 211
Provider Second Line Business Mailing Address:
THE WAKE UP PROGRAM LLC
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-2257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-372-4483
Provider Business Mailing Address Fax Number:
414-372-4483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 E AUER AVE SUITE 211
Provider Second Line Business Practice Location Address:
THE WAKE UP PROGRAM LLC
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212-2257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-372-4483
Provider Business Practice Location Address Fax Number:
414-372-4483
Provider Enumeration Date:
11/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  LPC 3748-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43594100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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