Provider Demographics
NPI:1770161887
Name:WILSON, WAYNE STEVEN JR
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:STEVEN
Last Name:WILSON
Suffix:JR
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 1:3500 IOWA AVE APT 412-A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7208
Mailing Address - Country:US
Mailing Address - Phone:310-924-4859
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:800-465-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician