Provider Demographics
NPI:1336386192
Name:WADE, TINA C
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:C
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:PO BOX 1765
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77834-1765
Mailing Address - Country:US
Mailing Address - Phone:979-661-4664
Mailing Address - Fax:
Practice Address - Street 1:1303 E ALAMO ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-3823
Practice Address - Country:US
Practice Address - Phone:979-661-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities