Provider Demographics
NPI:1619021276
Name:WADE, JOHN E (PSYD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:WADE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 E WHIPP RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2921
Mailing Address - Country:US
Mailing Address - Phone:937-384-3896
Mailing Address - Fax:937-281-0562
Practice Address - Street 1:1956 E WHIPP RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-2921
Practice Address - Country:US
Practice Address - Phone:937-433-5957
Practice Address - Fax:937-281-0562
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5936103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
311175717273OtherCARESOURCE
OH2544689Medicaid
OH5936OtherOHIO LICENSE
OH000000617539OtherANTHEM
OHCP30374Medicare PIN
OHWACP30372Medicare PIN
OH2544689Medicaid