Provider Demographics
NPI:1891994307
Name:FALCONBURG, WADE M (LCSW, ACADC)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:M
Last Name:FALCONBURG
Suffix:
Gender:M
Credentials:LCSW, ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 GAFFNEY RD STOP 7400
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5007
Mailing Address - Country:US
Mailing Address - Phone:208-577-1015
Mailing Address - Fax:
Practice Address - Street 1:202 2ND AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6158
Practice Address - Country:US
Practice Address - Phone:208-732-6112
Practice Address - Fax:208-732-6116
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACADC-90101YA0400X
ID283351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical