Provider Demographics
NPI:1124725825
Name:WADE, DEBORAH DIANE (LMT)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DIANE
Last Name:WADE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:DIANE
Other - Last Name:SEELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 2925
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-2925
Mailing Address - Country:US
Mailing Address - Phone:208-315-0863
Mailing Address - Fax:
Practice Address - Street 1:331 DEINHARD LN
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:208-315-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4344225700000X
CO23763225700000X
IDMAS-4463225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist