Provider Demographics
NPI:1790904167
Name:WADE, PAULA RENEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:RENEE
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 1:4215 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3116
Mailing Address - Country:US
Mailing Address - Phone:503-442-4862
Mailing Address - Fax:503-926-9161
Practice Address - Street 1:4215 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3116
Practice Address - Country:US
Practice Address - Phone:503-442-4862
Practice Address - Fax:503-926-9161
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3816106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist