Basic Information
| Provider Information | |||||||||
| NPI: | 1376708388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS-CLAY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MONICA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WATKINS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | MONICA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4970 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324466802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507185620 | ||||||||
| FaxNumber: | 8507185670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4970 HIGHWAY 90 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324466802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507185620 | ||||||||
| FaxNumber: | 8507185670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2008 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TF0200X | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TC0700X | PY7150 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.