Provider Demographics
NPI:1316436439
Name:WADE KILES, MARDREY ALICIA (LPC)
Entity type:Individual
Prefix:
First Name:MARDREY
Middle Name:ALICIA
Last Name:WADE KILES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 CHESHUNT LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3507
Mailing Address - Country:US
Mailing Address - Phone:901-870-8682
Mailing Address - Fax:901-424-9078
Practice Address - Street 1:5104 STAGE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3164
Practice Address - Country:US
Practice Address - Phone:901-646-1053
Practice Address - Fax:901-424-9078
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4255101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional