Provider Demographics
NPI:1659012854
Name:WADE, LONN MARCH (LLT,MMP)
Entity Type:Individual
Prefix:
First Name:LONN
Middle Name:MARCH
Last Name:WADE
Suffix:
Gender:M
Credentials:LLT,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W UNION BOWER RD APT 118
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-7516
Mailing Address - Country:US
Mailing Address - Phone:512-897-5163
Mailing Address - Fax:
Practice Address - Street 1:3317 FINLEY RD STE 223
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3200
Practice Address - Country:US
Practice Address - Phone:512-897-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT112763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT112763OtherLICENSE