Provider Demographics
NPI:1366420630
Name:BARDWELL, WAYNE ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALLEN
Last Name:BARDWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 KETTNER BLVD UNIT 1101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3459
Mailing Address - Country:US
Mailing Address - Phone:619-356-0138
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVE STE 212
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2382
Practice Address - Country:US
Practice Address - Phone:619-356-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16112103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS79175Medicare UPIN
CACP16112Medicare ID - Type Unspecified