Provider Demographics
NPI:1194381657
Name:WADE, LAURIE JEAN
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HASWELL RD
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-1302
Mailing Address - Country:US
Mailing Address - Phone:518-273-4911
Mailing Address - Fax:518-273-3312
Practice Address - Street 1:11 HASWELL RD
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-1302
Practice Address - Country:US
Practice Address - Phone:518-273-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0584081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical