Provider Demographics
NPI:1528552338
Name:WASHINGTON, WAYNE ALLEN (RADT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALLEN
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3917
Mailing Address - Country:US
Mailing Address - Phone:209-933-1888
Mailing Address - Fax:
Practice Address - Street 1:11540 MARSH CREEK RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:CA
Practice Address - Zip Code:94517-9759
Practice Address - Country:US
Practice Address - Phone:925-690-7904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1241170117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)