Provider Demographics
NPI:1124265186
Name:WADE, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
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 1:136 ROTUNDA DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-7304
Mailing Address - Country:US
Mailing Address - Phone:917-626-6399
Mailing Address - Fax:407-842-7921
Practice Address - Street 1:136 ROTUNDA DR
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-7304
Practice Address - Country:US
Practice Address - Phone:917-626-6399
Practice Address - Fax:407-842-7921
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst