Provider Demographics
NPI:1770058646
Name:WAYNE, GRAYSON DORIAN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:GRAYSON
Middle Name:DORIAN
Last Name:WAYNE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:PATRICK
Other - Last Name:MCGINTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2103
Practice Address - Country:US
Practice Address - Phone:978-937-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2264601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical