Provider Demographics
NPI:1942343603
Name:WADE, ELIZABETH SORRELL (LPC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SORRELL
Last Name:WADE
Suffix:
Gender:F
Credentials:LPC
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 131
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-0131
Mailing Address - Country:US
Mailing Address - Phone:903-253-1705
Mailing Address - Fax:903-586-0929
Practice Address - Street 1:514 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-4910
Practice Address - Country:US
Practice Address - Phone:903-253-1705
Practice Address - Fax:903-586-0929
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83882LOtherBLUE CROSS BLUE SHIELD
TX165842901Medicaid