Provider Demographics
NPI:1649580960
Name:WADE, LATONIA MECHELLA (LCSW)
Entity Type:Individual
Prefix:
First Name:LATONIA
Middle Name:MECHELLA
Last Name:WADE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E DEBBIE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3376
Mailing Address - Country:US
Mailing Address - Phone:219-808-0404
Mailing Address - Fax:
Practice Address - Street 1:4614 RAWHIDE TRAIL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065
Practice Address - Country:US
Practice Address - Phone:219-808-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX423311041C0700X
TXS42331171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator