Provider Demographics
NPI:1679658538
Name:BEAVER, WAYNE ALLEN (PH D)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALLEN
Last Name:BEAVER
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
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Mailing Address - Street 1:15848 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3143
Mailing Address - Country:US
Mailing Address - Phone:602-375-2974
Mailing Address - Fax:602-375-2974
Practice Address - Street 1:LUKE AIR FORCE BASE
Practice Address - Street 2:BLDG 317
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85309
Practice Address - Country:US
Practice Address - Phone:623-856-7579
Practice Address - Fax:623-856-4433
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ#978103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical