Provider Demographics
NPI:1366845935
Name:SUGIHARA, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:SUGIHARA
Suffix:
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 1:338 CATALPA ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2855
Mailing Address - Country:US
Mailing Address - Phone:650-817-9070
Mailing Address - Fax:650-246-3838
Practice Address - Street 1:300 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-817-9070
Practice Address - Fax:650-246-3838
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 101YM0800X
CAIMF92210106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health