Basic Information
Provider Information
NPI: 1033559513
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WAYNE
FirstName: CLYDE
MiddleName: CALVIN
NamePrefix:  
NameSuffix: JR.
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 418 W 4TH ST
Address2:  
City: ANTIOCH
State: CA
PostalCode: 945091245
CountryCode: US
TelephoneNumber: 5103931864
FaxNumber:  
Practice Location
Address1: 418 W 4TH ST
Address2:  
City: ANTIOCH
State: CA
PostalCode: 945091245
CountryCode: US
TelephoneNumber: 5103931864
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/28/2013
LastUpdateDate: 06/28/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X  Y Behavioral Health & Social Service ProvidersSocial Worker 

No ID Information.


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