Provider Demographics
NPI:1285162818
Name:WADE, JOHN (BCBA, MA OF ED L)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:BCBA, MA OF ED L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 W. GRANT RD.
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455
Mailing Address - Country:US
Mailing Address - Phone:231-742-0382
Mailing Address - Fax:
Practice Address - Street 1:4785 W. GRANT RD.
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455
Practice Address - Country:US
Practice Address - Phone:231-724-0382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401000424103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003914946Medicaid
MI7401000424OtherBEHAVIORAL ANALYST LICENSE