Provider Demographics
NPI:1881967909
Name:WAYNE, LASONDRA
Entity type:Individual
Prefix:
First Name:LASONDRA
Middle Name:
Last Name:WAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 GARDEN LN
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-4423
Mailing Address - Country:US
Mailing Address - Phone:269-612-4432
Mailing Address - Fax:
Practice Address - Street 1:7320 GARDEN LN
Practice Address - Street 2:SUITE 106
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4423
Practice Address - Country:US
Practice Address - Phone:269-612-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015047101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health