Provider Demographics
NPI:1982652368
Name:SPADE, EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SPADE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-7759
Mailing Address - Country:US
Mailing Address - Phone:732-762-3579
Mailing Address - Fax:
Practice Address - Street 1:94 STEVENS RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-1490
Practice Address - Country:US
Practice Address - Phone:732-914-1100
Practice Address - Fax:732-797-3830
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053655001041C0700X
FLSW76681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ105XOtherBCBS PROVIDER NUMBER