Provider Demographics
NPI:1417246448
Name:WASHINGTON, ROOSEVELT
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 E 450 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1734
Mailing Address - Country:US
Mailing Address - Phone:801-773-9149
Mailing Address - Fax:801-776-4162
Practice Address - Street 1:370 S 500 E STE 135
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-4001
Practice Address - Country:US
Practice Address - Phone:801-815-3443
Practice Address - Fax:801-776-4162
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor