Provider Demographics
NPI:1841731767
Name:WADE, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
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 1:8300 UTICA AVE
Mailing Address - Street 2:SUITE 259
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3879
Mailing Address - Country:US
Mailing Address - Phone:909-906-1505
Mailing Address - Fax:909-906-1508
Practice Address - Street 1:8300 UTICA AVE
Practice Address - Street 2:SUITE 259
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3879
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:909-906-1508
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician