Provider Demographics
NPI:1134786965
Name:FORMICA, WAYNE ARTHUR (MC LPC NCC)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ARTHUR
Last Name:FORMICA
Suffix:
Gender:M
Credentials:MC LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4767 E WOODSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7479
Mailing Address - Country:US
Mailing Address - Phone:602-561-5286
Mailing Address - Fax:
Practice Address - Street 1:4767 E WOODSIDE WAY
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7479
Practice Address - Country:US
Practice Address - Phone:602-561-5286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional