Provider Demographics
NPI:1114776309
Name:WADE, FEDENA C (LCSW)
Entity type:Individual
Prefix:
First Name:FEDENA
Middle Name:C
Last Name:WADE
Suffix:
Gender:F
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:PO BOX 2083
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23804-1383
Mailing Address - Country:US
Mailing Address - Phone:804-930-4720
Mailing Address - Fax:
Practice Address - Street 1:1115 FRANKLIN TPKE STE 10
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-1362
Practice Address - Country:US
Practice Address - Phone:804-930-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904016859101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker