Provider Demographics
NPI:1083163000
Name:OKADA, WATARU (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WATARU
Middle Name:
Last Name:OKADA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 ELMWOOD AVE # 240
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2213
Mailing Address - Country:US
Mailing Address - Phone:234-201-0577
Mailing Address - Fax:
Practice Address - Street 1:490 E RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:234-201-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0911691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY091169OtherNYS EDUCATION DEPT. OFFICE OF PROFESSIONS