Provider Demographics
NPI:1902092422
Name:WAYNE A. FORMICA
Entity Type:Organization
Organization Name:WAYNE A. FORMICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:480-677-4804
Mailing Address - Street 1:2055 W FRUIT TREE LN
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-6356
Mailing Address - Country:US
Mailing Address - Phone:480-677-4804
Mailing Address - Fax:480-677-4804
Practice Address - Street 1:2055 W FRUIT TREE LN
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-6356
Practice Address - Country:US
Practice Address - Phone:480-677-4804
Practice Address - Fax:480-677-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 10413251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health