Provider Demographics
NPI:1174017321
Name:WADE, AMANDA (LPC, CRC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 HARDING PL APT 546
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-0044
Mailing Address - Country:US
Mailing Address - Phone:540-798-8084
Mailing Address - Fax:
Practice Address - Street 1:851 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2979
Practice Address - Country:US
Practice Address - Phone:704-380-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00304135225C00000X
NC13701101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor