MEDICARE: WAYNE C PIERSEL PHD PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	1051	KS
2	103TC0700X	Clinical Psychologist	1051	KS
3	103TC1900X	Counseling Psychologist	1051	KS
4	103TC2200X	Clinical Child & Adolescent Psychologist	1051	KS
5	103TF0000X	Family Psychologist	1051	KS
6	103TM1800X	Intellectual & Developmental Disabilities Psychologist	1051	KS
7	103T00000X	Psychologist	1051	KS
8	103TS0200X	School Psychologist	1051	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	119040	OTHER	KS	BCBS
2	12555	OTHER	KS	PHS

General Provider Information

NPI Number	:	1457448201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE C PIERSEL PHD PSYCHOLOGY

Provider Business Mailing Address
First Line	:	8700 E 29TH STREET NORTH
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67226-2169
Country	:	US
Telephone Number	:	316-634-8710
Fax Number	:	316-634-8850

Provider Business Practice Location Address
First Line	:	8700 E 29TH STREET NORTH
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67226-2169
Country	:	US
Telephone Number	:	316-634-8710
Fax Number	:	316-634-8850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	09/05/2007

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