Healthcare Provider Details

I. General information

NPI: 1962116178
Provider Name (Legal Business Name): MATTHEW WATKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 PRESIDENT PL STE 110
SMYRNA TN
37167-6845
US

IV. Provider business mailing address

730 HAYSTACK LN
ANTIOCH TN
37013-5030
US

V. Phone/Fax

Practice location:
  • Phone: 615-852-5955
  • Fax:
Mailing address:
  • Phone: 404-574-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2856143
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: