Provider Demographics
NPI:1598382889
Name:WADE, LARISA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:WADE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 14TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2663
Mailing Address - Country:US
Mailing Address - Phone:360-359-3585
Mailing Address - Fax:
Practice Address - Street 1:2659 STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1627
Practice Address - Country:US
Practice Address - Phone:866-938-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61361392101YM0800X
CA18906101YM0800X
COLPC.0020639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health