Provider Demographics
NPI:1215957618
Name:SLIWA, WAYNE MICHAEL (EDD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:MICHAEL
Last Name:SLIWA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-359-4049
Mailing Address - Fax:563-359-4069
Practice Address - Street 1:2102 E 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:563-359-4069
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00402103T00000X
IL071-002353103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0012096Medicaid
IA0012096Medicaid