Provider Demographics
NPI:1215573373
Name:HEATH, WATARA
Entity Type:Individual
Prefix:
First Name:WATARA
Middle Name:
Last Name:HEATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 S DUPONT HWY STE 105
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4401
Mailing Address - Country:US
Mailing Address - Phone:302-442-6194
Mailing Address - Fax:302-442-6940
Practice Address - Street 1:1423 CAPITAL TRAIL
Practice Address - Street 2:POLLY DRUMMOND OFFICE PLAZA BLDG# 3
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711
Practice Address - Country:US
Practice Address - Phone:302-454-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ3-0000020104100000X
DE1339101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1339Medicaid
DEQ3-0000020Medicaid