Provider Demographics
NPI:1386141349
Name:WADE, DEIANDRA SHANEYCE (LPCA)
Entity type:Individual
Prefix:
First Name:DEIANDRA
Middle Name:SHANEYCE
Last Name:WADE
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 ELMER ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5801
Mailing Address - Country:US
Mailing Address - Phone:336-324-6333
Mailing Address - Fax:
Practice Address - Street 1:3409 W WENDOVER AVE STE I
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1579
Practice Address - Country:US
Practice Address - Phone:336-897-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health