Provider Demographics
NPI:1891994307
Name:FALCONBURG, WADE M (LCSW, MAC, PACT)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:M
Last Name:FALCONBURG
Suffix:
Gender:M
Credentials:LCSW, MAC, PACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61416
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99706-1416
Mailing Address - Country:US
Mailing Address - Phone:208-577-1015
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 61416
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99706-1416
Practice Address - Country:US
Practice Address - Phone:208-577-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACADC-90101YA0400X
ID283351041C0700X
AK2232021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)