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General NPI Number Information
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NPI Number | 1902092422
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Entity Type | Organization
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Legal Business Name | WAYNE A. FORMICA
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/18/2007
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Provider Practice Location Address
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Address Line | 2055 W FRUIT TREE LN
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City | QUEEN CREEK
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State | AZ
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Zip | 85242-6356
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Country | US
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Telephone | 480-677-4804
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Fax | 480-677-4804
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Provider Business Mailing Address
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Address Line | 2055 W FRUIT TREE LN
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City | QUEEN CREEK
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State | AZ
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Zip | 85242-6356
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Country | US
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Telephone | 480-677-4804
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Fax | 480-677-4804
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | MR. WAYNE ARTHUR FORMICA
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Credential | LPC
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Telephone | 480-677-4804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LPC 10413
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License Number State | AZ
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