Healthcare Provider Details

I. General information

NPI: 1407076938
Provider Name (Legal Business Name): WAYNE FRANKLIN AMENDOLA C.A.S.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MAIN ST
BINGHAMTON NY
13905-2522
US

IV. Provider business mailing address

461 LOOMIS HILL RD
DEPOSIT NY
13754-3630
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-6206
  • Fax:
Mailing address:
  • Phone: 917-301-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: