Healthcare Provider Details

I. General information

NPI: 1053976811
Provider Name (Legal Business Name): OCTAVIA ANTOINETTE WATKINS PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OCTAVIA ANTOINETTE WATKINS OCTAVIA WATKINS PHD

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37025 LA CONTEMPO AVE
PALMDALE CA
93550-7351
US

IV. Provider business mailing address

1607 E PALMDALE BLVD STE G
PALMDALE CA
93550-7801
US

V. Phone/Fax

Practice location:
  • Phone: 424-789-0439
  • Fax: 323-325-7163
Mailing address:
  • Phone: 424-789-0439
  • Fax: 323-325-7163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: