Provider Demographics
NPI:1669612727
Name:CHAN, WAYNE (PSYD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 HEARTHSTONE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4729
Mailing Address - Country:US
Mailing Address - Phone:510-590-6865
Mailing Address - Fax:
Practice Address - Street 1:1205 HEARTHSTONE LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4729
Practice Address - Country:US
Practice Address - Phone:510-590-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004177103T00000X
CAPSY27684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist