Provider Demographics
NPI:1477754935
Name:WADE, STEPHANIE LYNN (MFT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:WADE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:EVERHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:826 ROSE DR
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3601
Mailing Address - Country:US
Mailing Address - Phone:707-372-0227
Mailing Address - Fax:
Practice Address - Street 1:1125 MISSOURI ST STE 203E
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6065
Practice Address - Country:US
Practice Address - Phone:707-425-9670
Practice Address - Fax:707-425-9880
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43104106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist