Provider Demographics
NPI:1205580941
Name:CONWAY, WESLEY PAUL
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:PAUL
Last Name:CONWAY
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 1:109 SANDY BRAE DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-4960
Mailing Address - Country:US
Mailing Address - Phone:516-254-2954
Mailing Address - Fax:
Practice Address - Street 1:100 DEERFIELD PRESERVE BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5966
Practice Address - Country:US
Practice Address - Phone:516-254-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115144-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A