Provider Demographics
NPI:1811984107
Name:SPRAGUE, DAVID WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:SPRAGUE
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:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14021-0527
Mailing Address - Country:US
Mailing Address - Phone:585-356-1323
Mailing Address - Fax:585-344-8649
Practice Address - Street 1:12 ADAMS ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2902
Practice Address - Country:US
Practice Address - Phone:585-356-1323
Practice Address - Fax:585-344-8649
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-01
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010122-2103TC1900X
NY010122-1103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01-213-730Medicaid
NY276203Medicare PIN