Provider Demographics
NPI:1669505863
Name:DAVIS, WADE WILLIAM (MFT)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:WILLIAM
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 PRIMERA AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1558
Mailing Address - Country:US
Mailing Address - Phone:323-851-7573
Mailing Address - Fax:323-665-7903
Practice Address - Street 1:3351 PRIMERA AVE APT 6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1558
Practice Address - Country:US
Practice Address - Phone:323-851-7573
Practice Address - Fax:323-665-7903
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT31550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ53700ZOtherBLUE OF CALIFORNIA