Provider Demographics
NPI:1841756442
Name:THEODORE, WADELINE (LMHC)
Entity Type:Individual
Prefix:
First Name:WADELINE
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2001
Mailing Address - Country:US
Mailing Address - Phone:716-856-2587
Mailing Address - Fax:716-856-2608
Practice Address - Street 1:295 MAIN ST RM 1083
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-2510
Practice Address - Country:US
Practice Address - Phone:716-517-4297
Practice Address - Fax:716-259-9035
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009939101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health