Provider Demographics
NPI:1942226105
Name:DETIENNE, WAYNE E (CSW)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:DETIENNE
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 WARD ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1829
Mailing Address - Country:US
Mailing Address - Phone:877-838-4783
Mailing Address - Fax:888-958-4321
Practice Address - Street 1:2185 BROADWAY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2534
Practice Address - Country:US
Practice Address - Phone:877-838-4783
Practice Address - Fax:888-958-4321
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-4951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807299400Medicaid
ID807299400Medicaid