Healthcare Provider Details

I. General information

NPI: 1386819910
Provider Name (Legal Business Name): WAYNE BEHAVIORAL HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 NYE RD
LYONS NY
14489-9133
US

IV. Provider business mailing address

1519 NYE RD
LYONS NY
14489-9133
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-5722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KELLY SAMPLE
Title or Position: CMHP
Credential: MA
Phone: 315-946-5722