Healthcare Provider Details

I. General information

NPI: 1265880462
Provider Name (Legal Business Name): SUMMER WATKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

IV. Provider business mailing address

1798 39TH AVE APT 203
SAN FRANCISCO CA
94122-4062
US

V. Phone/Fax

Practice location:
  • Phone: 415-507-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number71113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: