Provider Demographics
NPI:1619936788
Name:CARPENTER, WAYNE LEWIS (MA, PSYCH)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:LEWIS
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:MA, PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 PETERSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2986
Mailing Address - Country:US
Mailing Address - Phone:970-224-1778
Mailing Address - Fax:970-472-6590
Practice Address - Street 1:218 PETERSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2986
Practice Address - Country:US
Practice Address - Phone:970-224-1778
Practice Address - Fax:970-472-6590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO015106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist