Provider Demographics
NPI:1104959394
Name:WAYNE, MONICA YVONNE
Entity type:Individual
Prefix:MS
First Name:MONICA
Middle Name:YVONNE
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 1:3925 VAN BUREN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3620
Mailing Address - Country:US
Mailing Address - Phone:951-359-5760
Mailing Address - Fax:951-359-2024
Practice Address - Street 1:8485 TAMARIND AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3975
Practice Address - Country:US
Practice Address - Phone:909-428-2366
Practice Address - Fax:909-428-2363
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50587106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50587OtherREGISTERED MFT INTERN