Healthcare Provider Details

I. General information

NPI: 1679743389
Provider Name (Legal Business Name): RICHARD WAYNE WOOTEN M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

5429 ORCHARD AVE
DEARBORN MI
48126-3052
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7701
  • Fax:
Mailing address:
  • Phone: 313-779-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: