Provider Demographics
NPI:1689224750
Name:WADE, TIMOTHY M JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
Last Name:WADE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:1443 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3224
Practice Address - Country:US
Practice Address - Phone:401-273-8100
Practice Address - Fax:401-861-8696
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW022051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical