Provider Demographics
NPI:1922427772
Name:WAITT, ROGER (LICSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:WAITT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8029
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-0029
Mailing Address - Country:US
Mailing Address - Phone:978-869-3129
Mailing Address - Fax:
Practice Address - Street 1:18 BROADWAY CIR
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904
Practice Address - Country:US
Practice Address - Phone:978-828-7315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1227901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical