Provider Demographics
NPI:1740682806
Name:WATFORD, RAKENDRIA
Entity type:Individual
Prefix:
First Name:RAKENDRIA
Middle Name:
Last Name:WATFORD
Suffix:
Gender:F
Credentials:
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 31
Mailing Address - Street 2:
Mailing Address - City:MERRY HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27957-0031
Mailing Address - Country:US
Mailing Address - Phone:252-484-0739
Mailing Address - Fax:
Practice Address - Street 1:912 NC HWY 45 S
Practice Address - Street 2:
Practice Address - City:COFIELD
Practice Address - State:NC
Practice Address - Zip Code:27922-0000
Practice Address - Country:US
Practice Address - Phone:252-484-0739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-20
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NC27967174235Z00000X, 390200000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program