Provider Demographics
NPI:1902220825
Name:WADE, MARY C (MED, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WADE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 RIDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-2684
Mailing Address - Country:US
Mailing Address - Phone:404-480-0430
Mailing Address - Fax:
Practice Address - Street 1:85 GOLF CREST DR
Practice Address - Street 2:SUITE 309
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-2698
Practice Address - Country:US
Practice Address - Phone:404-480-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA462269101YS0200X
GALPC007481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool