Provider Demographics
NPI:1205342292
Name:DEWATER, ADAM (RBT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DEWATER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11665 AVENA PL STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-19744106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician