Provider Demographics
NPI:1760193114
Name:WADE, MATTHEW LUKE (MFT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LUKE
Last Name:WADE
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 1:204 N MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-1815
Mailing Address - Country:US
Mailing Address - Phone:615-988-8823
Mailing Address - Fax:
Practice Address - Street 1:204 N MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1815
Practice Address - Country:US
Practice Address - Phone:615-988-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN921236194OtherLLC