Provider Demographics
NPI:1851935886
Name:WILKS, WAYNE ANTHONY
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ANTHONY
Last Name:WILKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 NW SAINT JAMES DR # 431
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3444
Mailing Address - Country:US
Mailing Address - Phone:407-545-1258
Mailing Address - Fax:
Practice Address - Street 1:702 N 27TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-5931
Practice Address - Country:US
Practice Address - Phone:407-545-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional