Healthcare Provider Details

I. General information

NPI: 1902683931
Provider Name (Legal Business Name): SAM WAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S HIGH ST
WEST CHESTER PA
19383-0002
US

IV. Provider business mailing address

1504 WOODSDALE RD
WILMINGTON DE
19809-2247
US

V. Phone/Fax

Practice location:
  • Phone: 610-436-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: