Basic Information
| Provider Information | |||||||||
| NPI: | 1003154170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAATSA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C.C., L.A.D.A.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 339 | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873270339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057825719 | ||||||||
| FaxNumber: | 5057825735 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 RT 301 NORTH | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057825719 | ||||||||
| FaxNumber: | 5057825735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0159721 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 0156201 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CCMH0208201 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.