Provider Demographics
NPI:1457453763
Name:LAVENGOOD, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:LAVENGOOD
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:P O BOX HH
Mailing Address - Street 2:BUSINESS DEVELOPMENT & CONTRACTING
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93942
Mailing Address - Country:US
Mailing Address - Phone:831-622-2716
Mailing Address - Fax:831-625-4764
Practice Address - Street 1:23625 WR HOLMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:831-624-5311
Practice Address - Fax:831-625-4948
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS33741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36341ZMedicare ID - Type Unspecified