Provider Demographics
NPI:1033559513
Name:WAYNE, CLYDE CALVIN JR
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:CALVIN
Last Name:WAYNE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-1245
Mailing Address - Country:US
Mailing Address - Phone:510-393-1864
Mailing Address - Fax:
Practice Address - Street 1:418 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-1245
Practice Address - Country:US
Practice Address - Phone:510-393-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker