Healthcare Provider Details

I. General information

NPI: 1437744455
Provider Name (Legal Business Name): WAITS PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 WOODBURN ST
RUSTON LA
71270-8520
US

IV. Provider business mailing address

3816 WOODBURN ST
RUSTON LA
71270-8520
US

V. Phone/Fax

Practice location:
  • Phone: 850-830-2264
  • Fax:
Mailing address:
  • Phone: 850-830-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN B WAITS
Title or Position: PROVIDER/PSYCHOLOGIST
Credential: PHD
Phone: 850-830-2264