Provider Demographics
NPI:1982880977
Name:SPADE, ELTON L (LCSW)
Entity Type:Individual
Prefix:
First Name:ELTON
Middle Name:L
Last Name:SPADE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22446 SPICEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9156
Mailing Address - Country:US
Mailing Address - Phone:574-875-1917
Mailing Address - Fax:
Practice Address - Street 1:22446 SPICEWOOD DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-9156
Practice Address - Country:US
Practice Address - Phone:574-875-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003237A101YM0800X
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health