Provider Demographics
NPI:1831766302
Name:WADE, STEPHANIE RENEA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEA
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 1:6817 TIKI LN APT 4
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-7167
Mailing Address - Country:US
Mailing Address - Phone:479-409-9806
Mailing Address - Fax:
Practice Address - Street 1:4400 BAYOU BLVD STE 20
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1908
Practice Address - Country:US
Practice Address - Phone:816-623-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21158101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health