Basic Information
| Provider Information | |||||||||
| NPI: | 1942226105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETIENNE | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5310 WARD ROAD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800021829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778384783 | ||||||||
| FaxNumber: | 8889584321 | ||||||||
| Practice Location | |||||||||
| Address1: | 2185 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802052534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778384783 | ||||||||
| FaxNumber: | 8889584321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-495 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 807299400 | 05 | ID | MEDICAID |