Provider Demographics
NPI:1477859940
Name:W WADE PHD LP LLC
Entity Type:Organization
Organization Name:W WADE PHD LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LP
Authorized Official - Phone:612-385-6392
Mailing Address - Street 1:4500 PARK GLEN RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4871
Mailing Address - Country:US
Mailing Address - Phone:952-929-9478
Mailing Address - Fax:952-929-9548
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:SUITE 270
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:952-929-9478
Practice Address - Fax:952-929-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5259261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health