Provider Demographics
NPI:1245920495
Name:WATSON, ROGER JOHN K
Entity type:Individual
Prefix:
First Name:ROGER JOHN
Middle Name:K
Last Name:WATSON
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 1:91-1692 ORRICK ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2096
Mailing Address - Country:US
Mailing Address - Phone:808-216-9740
Mailing Address - Fax:
Practice Address - Street 1:91-1692 ORRICK ST
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2096
Practice Address - Country:US
Practice Address - Phone:808-216-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI49791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical