Provider Demographics
NPI:1629779145
Name:WISTERIA COUNSELING
Entity Type:Organization
Organization Name:WISTERIA COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:267-386-5432
Mailing Address - Street 1:121 N MAIN ST STE 310
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-1799
Mailing Address - Country:US
Mailing Address - Phone:267-354-0113
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST STE 310
Practice Address - Street 2:
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-1799
Practice Address - Country:US
Practice Address - Phone:267-354-0113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty