Provider Demographics
NPI:1861792202
Name:WATKINS, ALFONZO (MSE, LPC)
Entity type:Individual
Prefix:MR
First Name:ALFONZO
Middle Name:
Last Name:WATKINS
Suffix:
Gender:M
Credentials:MSE, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E AUER AVE SUITE 211
Mailing Address - Street 2:THE WAKE UP PROGRAM LLC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2257
Mailing Address - Country:US
Mailing Address - Phone:414-372-4483
Mailing Address - Fax:414-372-4483
Practice Address - Street 1:1230 E AUER AVE SUITE 211
Practice Address - Street 2:THE WAKE UP PROGRAM LLC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2257
Practice Address - Country:US
Practice Address - Phone:414-372-4483
Practice Address - Fax:414-372-4483
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WILPC 3748-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43594100Medicaid