Provider Demographics
NPI:1093044695
Name:WAITE, ROBERT J (OT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WAITE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:J
Other - Last Name:SEMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1803 W BLODGETT ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3914
Mailing Address - Country:US
Mailing Address - Phone:575-302-6648
Mailing Address - Fax:
Practice Address - Street 1:1351 FOWLER ST STE 110
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4714
Practice Address - Country:US
Practice Address - Phone:509-942-2574
Practice Address - Fax:509-942-2575
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60772514225X00000X
NM2659225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2084432Medicaid