Provider Demographics
NPI:1528331154
Name:WAITS, JOHN BRANDON (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRANDON
Last Name:WAITS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 WOODBURN ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-8520
Mailing Address - Country:US
Mailing Address - Phone:850-830-2264
Mailing Address - Fax:
Practice Address - Street 1:206 E REYNOLDS DR STE F2
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2809
Practice Address - Country:US
Practice Address - Phone:318-224-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA1488103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health