Provider Demographics
NPI:1396764163
Name:RICHARD, WAYNE CAMMER (PHD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:CAMMER
Last Name:RICHARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1957
Mailing Address - Country:US
Mailing Address - Phone:850-862-3141
Mailing Address - Fax:850-862-7732
Practice Address - Street 1:235 CARMEL DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1957
Practice Address - Country:US
Practice Address - Phone:850-862-3141
Practice Address - Fax:850-862-7732
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2540103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54474OtherBLUE CROSS BLUE SHIELD
FLE2386ZMedicare ID - Type Unspecified