Provider Demographics
NPI:1033126875
Name:MEDDOCK, WAYNE DOUGLAS (LMHC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:DOUGLAS
Last Name:MEDDOCK
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 TECHSTER BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4805
Mailing Address - Country:US
Mailing Address - Phone:239-223-2751
Mailing Address - Fax:
Practice Address - Street 1:6360 TECHSTER BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4805
Practice Address - Country:US
Practice Address - Phone:239-223-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2606101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768549100Medicaid
FL762197300Medicaid