Provider Demographics
NPI:1669483335
Name:REZNICK, WAYNE MERL (PHD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:MERL
Last Name:REZNICK
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 1:1225 MARTHA CUSTIS DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2000
Mailing Address - Country:US
Mailing Address - Phone:703-379-9520
Mailing Address - Fax:703-379-9529
Practice Address - Street 1:1225 MARTHA CUSTIS DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2000
Practice Address - Country:US
Practice Address - Phone:703-379-9520
Practice Address - Fax:703-379-9529
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00B334D70Medicare ID - Type Unspecified
VAG00970Medicare UPIN