Provider Demographics
NPI:1710521307
Name:WADE, STACEY L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
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 1:5 SALT MARSH QUAY APT B
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-7025
Mailing Address - Country:US
Mailing Address - Phone:757-714-4336
Mailing Address - Fax:
Practice Address - Street 1:12997 NETTLES DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6913
Practice Address - Country:US
Practice Address - Phone:888-365-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040106141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical