Provider Demographics
NPI:1912331299
Name:ALLEN-WADE, LAURA L (MA, LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:ALLEN-WADE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11644 W MOUNT HOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8708
Mailing Address - Country:US
Mailing Address - Phone:208-409-7069
Mailing Address - Fax:
Practice Address - Street 1:7161 W POTOMAC DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9148
Practice Address - Country:US
Practice Address - Phone:208-908-6399
Practice Address - Fax:866-275-9883
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5259101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional