Healthcare Provider Details

I. General information

NPI: 1376935809
Provider Name (Legal Business Name): DR. PHILIP ALLEN WATKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 FROG HOLLER LN
AUGUSTA ME
04330-0453
US

IV. Provider business mailing address

12 FROG HOLLER LN
AUGUSTA ME
04330-0453
US

V. Phone/Fax

Practice location:
  • Phone: 207-458-4403
  • Fax:
Mailing address:
  • Phone: 207-458-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC525
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLP508
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: