1457148405 NPI number — WAYNE WILSON LICENSED CLINICAL SOCIAL WORKER INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457148405 NPI number — WAYNE WILSON LICENSED CLINICAL SOCIAL WORKER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE WILSON LICENSED CLINICAL SOCIAL WORKER INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457148405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 TOWN CENTER DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 TOWN CENTER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-949-0009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2025

Additional Information

Authorized Official

Authorized Official Last Name:
DUNGO
Authorized Official First Name:
KATELYN
Authorized Official Middle Name:
Authorized Official Title or Position:
HUMAN RESOURCES
Authorized Official Telephone Number:
208-869-8386

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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