Basic Information
Provider Information
NPI: 1003154170
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WAATSA
FirstName: ROBERT
MiddleName: K.
NamePrefix: MR.
NameSuffix:  
Credential: L.M.H.C., L.A.D.A.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 339
Address2: ZUNI RECOVERY CENTER
City: ZUNI
State: NM
PostalCode: 873270339
CountryCode: US
TelephoneNumber: 5057824710
FaxNumber: 5057825880
Practice Location
Address1: 101 D AVENUE
Address2: BLACK ROCK
City: ZUNI
State: NM
PostalCode: 87327
CountryCode: US
TelephoneNumber: 5057824710
FaxNumber: 5057825880
Other Information
ProviderEnumerationDate: 01/24/2013
LastUpdateDate: 07/17/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X0159721NMN Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800X0156201NMY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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