Basic Information
| Provider Information | |||||||||
| NPI: | 1033559513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAYNE | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | CALVIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.