Provider Demographics
NPI:1861705485
Name:WAITES, JUANITA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JUANITA
Middle Name:MARIE
Last Name:WAITES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:NITA
Other - Middle Name:MARIE
Other - Last Name:WAITES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:905 MAIN ST STE 508
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6062
Mailing Address - Country:US
Mailing Address - Phone:541-331-3152
Mailing Address - Fax:833-263-0939
Practice Address - Street 1:905 MAIN ST STE 508
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6062
Practice Address - Country:US
Practice Address - Phone:541-331-3152
Practice Address - Fax:833-263-0939
Is Sole Proprietor?:No
Enumeration Date:2010-07-24
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1878103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500693464Medicaid