Provider Demographics
NPI:1720145279
Name:WADE, AMANDA J (MA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:J
Last Name:WADE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2541
Mailing Address - Country:US
Mailing Address - Phone:270-782-1116
Mailing Address - Fax:270-782-9108
Practice Address - Street 1:1215 HIGH ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2541
Practice Address - Country:US
Practice Address - Phone:270-782-1116
Practice Address - Fax:270-782-9108
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0757103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist