Provider Demographics
NPI:1518607639
Name:WAYNE, EMILY SUZANNE (LPCC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:SUZANNE
Last Name:WAYNE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3949
Mailing Address - Country:US
Mailing Address - Phone:612-584-1983
Mailing Address - Fax:
Practice Address - Street 1:2526 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3949
Practice Address - Country:US
Practice Address - Phone:612-584-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCC02947OtherLPCC