Provider Demographics
NPI:1396209136
Name:CLARK, WAYNE E (CASAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 BENEDICT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4404
Mailing Address - Country:US
Mailing Address - Phone:646-316-3265
Mailing Address - Fax:
Practice Address - Street 1:820 SAINT ANNS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-7885
Practice Address - Country:US
Practice Address - Phone:646-316-3265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23387101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)