Provider Demographics
NPI:1407862402
Name:WADE, AUTUMN R (OTR L, CLT)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:R
Last Name:WADE
Suffix:
Gender:F
Credentials:OTR L, CLT
Other - Prefix:MISS
Other - First Name:AUTUMN
Other - Middle Name:R
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:WESTERNPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21562-1711
Mailing Address - Country:US
Mailing Address - Phone:301-359-8955
Mailing Address - Fax:
Practice Address - Street 1:157 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2319
Practice Address - Country:US
Practice Address - Phone:301-722-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05586225X00000X
VA0119004134225X00000X
PAOC009784225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist