MEDICARE: MR. WAYNE LEWIS CARPENTER MA, PSYCH

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	106H00000X	Marriage & Family Therapist	015	CO

General Provider Information

NPI Number	:	1619936788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WAYNE LEWIS CARPENTER MA, PSYCH

Provider Business Mailing Address
First Line	:	218 PETERSON ST
Second Line	:	SUITE A
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2986
Country	:	US
Telephone Number	:	970-224-1778
Fax Number	:	970-472-6590

Provider Business Practice Location Address
First Line	:	218 PETERSON ST
Second Line	:	SUITE A
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2986
Country	:	US
Telephone Number	:	970-224-1778
Fax Number	:	970-472-6590

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

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	07/08/2007

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