Provider Demographics
NPI:1689494627
Name:WATKINS, BURGANDY
Entity type:Individual
Prefix:
First Name:BURGANDY
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5044 COOPERS LANDING DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-6652
Mailing Address - Country:US
Mailing Address - Phone:269-290-5774
Mailing Address - Fax:
Practice Address - Street 1:1800 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9688
Practice Address - Country:US
Practice Address - Phone:269-250-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician