Provider Demographics
NPI:1851862718
Name:JUANITA WAITES PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:JUANITA WAITES PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAITES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:541-331-3152
Mailing Address - Street 1:2384 LINDA VISTA DR APT 3
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-2300
Mailing Address - Country:US
Mailing Address - Phone:541-331-3152
Mailing Address - Fax:833-263-0939
Practice Address - Street 1:905 MAIN ST STE 502
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health