Provider Demographics
NPI:1871650291
Name:WADE, PRISCILLA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4455
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48826-4455
Mailing Address - Country:US
Mailing Address - Phone:517-336-7366
Mailing Address - Fax:517-336-0808
Practice Address - Street 1:4123 OKEMOS RD STE 15
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2818
Practice Address - Country:US
Practice Address - Phone:517-336-7366
Practice Address - Fax:517-336-0808
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007011103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI063276OtherCONNECTICUT GENERAL
MI063276OtherGENERAL MOTORS
MI1016708OtherMCLAREN
MI11291411OtherBLUE CROSS TRUST
MI68OC34678OtherBLUE CROSS BLUE SHIELD
MI78357OtherCONNECTICUT GENERAL
MIA029412OtherVENDOR NUMBER
MIMI5228936OtherBLUE CARE NETWORK
MIR67036OtherMAGELLAN
MI03626OtherVALUE OPTIONS
MI228936000OtherMAGELLAN