Provider Demographics
NPI:1154408243
Name:ANDERSON, WADE GREGORY (LCSW)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:GREGORY
Last Name:ANDERSON
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 1:1713 EAGLE TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-3313
Mailing Address - Country:US
Mailing Address - Phone:727-492-5608
Mailing Address - Fax:727-784-2209
Practice Address - Street 1:1713 EAGLE TRACE BLVD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-3313
Practice Address - Country:US
Practice Address - Phone:727-492-5608
Practice Address - Fax:727-784-2209
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 61851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1606Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER