Provider Demographics
NPI:1679204739
Name:WADE, MARIAH KALON SCOTT
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:KALON SCOTT
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16722 W BRILES RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-6818
Mailing Address - Country:US
Mailing Address - Phone:951-332-1079
Mailing Address - Fax:
Practice Address - Street 1:4100 S LINDSAY RD STE 113
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-1507
Practice Address - Country:US
Practice Address - Phone:480-219-3953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA137972355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant