Provider Demographics
NPI:1073608626
Name:FLEISIG, WAYNE EVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:EVAN
Last Name:FLEISIG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 CRESTBROOK ROAD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35223
Mailing Address - Country:US
Mailing Address - Phone:205-969-2963
Mailing Address - Fax:
Practice Address - Street 1:1600 7TH AVENUE SOUTH
Practice Address - Street 2:ACC SUITE 500
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-939-9193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL715103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-46084OtherBCBS
AL515-01261OtherFEDERAL BC
AL00915130Medicaid
AL1073608626OtherTRICARE SOUTH
AL510-46083OtherBLUE CROSS BLUE SHIELD
AL510-46083OtherBCBS
AL101797Medicaid
AL000046084Medicaid
AL000046083FLEMedicare ID - Type Unspecified
AL000046084Medicaid