Provider Demographics
NPI:1104234947
Name:WADE, VONZELL
Entity type:Individual
Prefix:
First Name:VONZELL
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 FARM HILL CT
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-5807
Mailing Address - Country:US
Mailing Address - Phone:724-594-7670
Mailing Address - Fax:
Practice Address - Street 1:408 8TH ST STE 5
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6426
Practice Address - Country:US
Practice Address - Phone:724-212-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006804101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor