Healthcare Provider Details

I. General information

NPI: 1295067973
Provider Name (Legal Business Name): WAYNE R MACINTOSH MA, LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 CAMPBELL THICKETT RD
RIDGEVILLE SC
29472-6339
US

IV. Provider business mailing address

204 ELM HALL CIR
SUMMERVILLE SC
29483-1613
US

V. Phone/Fax

Practice location:
  • Phone: 843-821-2073
  • Fax:
Mailing address:
  • Phone: 248-767-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010026
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: