Provider Demographics
NPI:1427355650
Name:POULSEN, WADE
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:
Last Name:POULSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 1300 S
Mailing Address - Street 2:SUITE 501
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5482
Mailing Address - Country:US
Mailing Address - Phone:385-468-3559
Mailing Address - Fax:385-468-3560
Practice Address - Street 1:145 E 1300 S
Practice Address - Street 2:SUITE 501
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5482
Practice Address - Country:US
Practice Address - Phone:385-468-3559
Practice Address - Fax:385-468-3560
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7966792-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health