Provider Demographics
NPI:1295286169
Name:WADE, DEKKIA
Entity type:Individual
Prefix:
First Name:DEKKIA
Middle Name:
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 1:10871 BRIGHT FOX DR
Mailing Address - Street 2:APT. 203
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-9261
Mailing Address - Country:US
Mailing Address - Phone:317-366-6391
Mailing Address - Fax:
Practice Address - Street 1:10871 BRIGHT FOX DR
Practice Address - Street 2:APT. 203
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-9261
Practice Address - Country:US
Practice Address - Phone:317-366-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0921347143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician