MEDICARE: DR. JOHN BRANDON WAITS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	103TC1900X	Counseling Psychologist	1488	LA

General Provider Information

NPI Number	:	1528331154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BRANDON WAITS PH.D.

Provider Business Mailing Address
First Line	:	3816 WOODBURN ST
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-8520
Country	:	US
Telephone Number	:	850-830-2264
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 E REYNOLDS DR STE F2
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-2809
Country	:	US
Telephone Number	:	318-224-7223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	03/04/2021

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