Provider Demographics
NPI:1598352338
Name:WADE, LEON D
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:D
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 GARDENVIEW ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-3369
Mailing Address - Country:US
Mailing Address - Phone:330-227-4858
Mailing Address - Fax:
Practice Address - Street 1:1043 GARDENVIEW ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-3369
Practice Address - Country:US
Practice Address - Phone:330-227-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6705758OtherDEPARTMENT OF OHIO DEVELOPMENTAL DISABILITIES