Provider Demographics
NPI:1942082169
Name:WAITE, RICHARD ALLEN
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:WAITE
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 1:910 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-2719
Mailing Address - Country:US
Mailing Address - Phone:917-608-7960
Mailing Address - Fax:
Practice Address - Street 1:26 COURT ST STE 1302
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-1113
Practice Address - Country:US
Practice Address - Phone:929-430-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121032-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker