Provider Demographics
NPI:1245831775
Name:WADE, KARLA SAMANTHA
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:SAMANTHA
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 1:2428 EASTRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1114
Mailing Address - Country:US
Mailing Address - Phone:619-571-8451
Mailing Address - Fax:
Practice Address - Street 1:7090 MIRATECH DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3109
Practice Address - Country:US
Practice Address - Phone:619-571-8451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst