MEDICARE: DR. WAYNE J EHRISMAN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	21061	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CC95	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1194867622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE J EHRISMAN PHD

Provider Business Mailing Address
First Line	:	402 MARY LOUISE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-4433
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 MARY LOUISE DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78201-4433
Country	:	US
Telephone Number	:	210-733-7669
Fax Number	:	210-733-7669

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/08/2007

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