Provider Demographics
NPI:1730299819
Name:RAITER, WAYNE JOHN (MA LICSW)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:JOHN
Last Name:RAITER
Suffix:
Gender:M
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:612-861-6129
Mailing Address - Fax:612-861-7589
Practice Address - Street 1:6701 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423
Practice Address - Country:US
Practice Address - Phone:612-861-6129
Practice Address - Fax:612-861-7589
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN040441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN117J5RAOtherBCBS