Basic Information
| Provider Information | |||||||||
| NPI: | 1356596282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 BOBALA RD | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010409632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135365473 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 417 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011043736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137470705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 001701 | CT | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 6625 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.