Provider Demographics
NPI:1598382889
Name:WADE, LARISA
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10224 FISCHER PL NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7730
Mailing Address - Country:US
Mailing Address - Phone:360-359-3585
Mailing Address - Fax:
Practice Address - Street 1:14803 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-7110
Practice Address - Country:US
Practice Address - Phone:206-631-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health