Provider Demographics
NPI:1093240780
Name:WADE, ALFORD
Entity Type:Individual
Prefix:
First Name:ALFORD
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8217 CEDARCREST LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-4631
Mailing Address - Country:US
Mailing Address - Phone:817-845-9663
Mailing Address - Fax:
Practice Address - Street 1:4701 ALTAMESA BLVD STE 1F
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6135
Practice Address - Country:US
Practice Address - Phone:817-370-1223
Practice Address - Fax:817-370-1225
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional