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.