Provider Demographics
NPI:1437448362
Name:WASHBURN, WAYDE JENNINGS (CAC II, NCAC I)
Entity Type:Individual
Prefix:
First Name:WAYDE
Middle Name:JENNINGS
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:CAC II, NCAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SMITH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2780
Mailing Address - Country:US
Mailing Address - Phone:706-594-4735
Mailing Address - Fax:706-243-4701
Practice Address - Street 1:100 SMITH ST STE 1
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2780
Practice Address - Country:US
Practice Address - Phone:706-594-4735
Practice Address - Fax:706-243-4701
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0858101YA0400X
GA012692101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)