Provider Demographics
NPI:1205597416
Name:WADE, CARLA JO (LCAC,LMLP)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JO
Last Name:WADE
Suffix:
Gender:F
Credentials:LCAC,LMLP
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:JO
Other - Last Name:WITTER LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-2206
Mailing Address - Country:US
Mailing Address - Phone:316-283-6743
Mailing Address - Fax:
Practice Address - Street 1:3820 N TOBEN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2903
Practice Address - Country:US
Practice Address - Phone:316-634-3954
Practice Address - Fax:316-634-3956
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS953101YA0400X
KS247101YA0400X
KS10848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)