Provider Demographics
NPI:1548475494
Name:WAYNE, JOHN D A (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D A
Last Name:WAYNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:D
Other - Last Name:WAYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:625 FAIR OAKS AVE
Mailing Address - Street 2:SUITE 374
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2630
Mailing Address - Country:US
Mailing Address - Phone:626-441-0277
Mailing Address - Fax:626-441-6131
Practice Address - Street 1:625 FAIR OAKS AVE
Practice Address - Street 2:SUITE 374
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2630
Practice Address - Country:US
Practice Address - Phone:626-441-0277
Practice Address - Fax:626-441-6131
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13553103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP13553Medicare ID - Type Unspecified