Healthcare Provider Details

I. General information

NPI: 1083163000
Provider Name (Legal Business Name): WATARU OKADA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 07/17/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 E RIDGE ROAD
ROCHESTER NY
14621
US

IV. Provider business mailing address

2604 ELMWOOD AVE # 240
ROCHESTER NY
14618-2213
US

V. Phone/Fax

Practice location:
  • Phone: 234-201-0577
  • Fax:
Mailing address:
  • Phone: 234-201-0577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: