Provider Demographics
NPI:1841582020
Name:CENTRA, WAYNE BRIAN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:BRIAN
Last Name:CENTRA
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 DOW AVE
Mailing Address - Street 2:114
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7233
Mailing Address - Country:US
Mailing Address - Phone:714-731-4668
Mailing Address - Fax:714-464-4668
Practice Address - Street 1:3002 DOW AVE
Practice Address - Street 2:114
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7233
Practice Address - Country:US
Practice Address - Phone:714-731-4668
Practice Address - Fax:714-464-4668
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT-5499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist