Provider Demographics
NPI:1205964806
Name:WAYNE, COLLEEN M (BS)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:M
Last Name:WAYNE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 N DRINKWATER BLVD APT 272
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3958
Mailing Address - Country:US
Mailing Address - Phone:602-523-8715
Mailing Address - Fax:
Practice Address - Street 1:811 N 13TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3400
Practice Address - Country:US
Practice Address - Phone:602-523-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#SLPL5214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145954Medicaid