Provider Demographics
NPI:1568716546
Name:WADE, DIEDRE L (MA LPCC)
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:L
Last Name:WADE
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FAIRFAX AVE
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4939
Mailing Address - Country:US
Mailing Address - Phone:502-512-0133
Mailing Address - Fax:
Practice Address - Street 1:130 FAIRFAX AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4939
Practice Address - Country:US
Practice Address - Phone:502-512-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPROCOUPCC00211336101YP2500X
KY1347101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100345050Medicaid