Provider Demographics
NPI:1366789851
Name:WAYNE, ANDRE JAMAR (TLLP)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:JAMAR
Last Name:WAYNE
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S BURDICK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5221
Mailing Address - Country:US
Mailing Address - Phone:269-381-3700
Mailing Address - Fax:269-381-3810
Practice Address - Street 1:610 S BURDICK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5221
Practice Address - Country:US
Practice Address - Phone:269-381-3700
Practice Address - Fax:269-381-3810
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013835103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling