Provider Demographics
NPI:1558796201
Name:WAYNE, GWENDOLYN (LCSW, CMTPT, LMT)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:WAYNE
Suffix:
Gender:F
Credentials:LCSW, CMTPT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-0515
Mailing Address - Country:US
Mailing Address - Phone:203-488-6411
Mailing Address - Fax:
Practice Address - Street 1:17 OLD HICKORY LN
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2827
Practice Address - Country:US
Practice Address - Phone:203-488-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000394225400000X
CT86681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner