Provider Demographics
NPI:1003576083
Name:WADE, LISA BETH
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 E CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61559-9596
Mailing Address - Country:US
Mailing Address - Phone:309-678-0363
Mailing Address - Fax:
Practice Address - Street 1:6901 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3193
Practice Address - Country:US
Practice Address - Phone:309-692-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000996225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology