Provider Demographics
NPI:1164520029
Name:GORE, WAYNE BRUCE (MED, CSAC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:BRUCE
Last Name:GORE
Suffix:
Gender:M
Credentials:MED, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37202 BOLYN RD
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-4111
Mailing Address - Country:US
Mailing Address - Phone:540-338-5432
Mailing Address - Fax:
Practice Address - Street 1:102 HERITAGE WAY NE STE 302
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5100
Practice Address - Fax:703-777-0170
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)