Provider Demographics
NPI:1255658860
Name:SHADE, CHADWICK J (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHADWICK
Middle Name:J
Last Name:SHADE
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 1:5955 ZEAMER AVENUE
Mailing Address - Street 2:3RD MDG
Mailing Address - City:ELMENDORF AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-2181
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVENUE
Practice Address - Street 2:3RD MDG
Practice Address - City:ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPSY0091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical