Healthcare Provider Details

I. General information

NPI: 1114627932
Provider Name (Legal Business Name): DWAIN LEWIS WATTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9875 GOOD LUCK RD APT 11
LANHAM MD
20706-3231
US

IV. Provider business mailing address

9875 GOOD LUCK RD APT 11
LANHAM MD
20706-3231
US

V. Phone/Fax

Practice location:
  • Phone: 202-417-0521
  • Fax:
Mailing address:
  • Phone: 202-417-0521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: