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NPI Code Detail

MEDICARE: MR. TIMOTHY SHANE WADE

MEDICARE: MR. TIMOTHY SHANE WADE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist124814CA

General Provider Information

NPI Number : 1083913321
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TIMOTHY SHANE WADE
Provider Business Mailing Address
First Line : 2120 ALPINE BLVD
Second Line :
City : ALPINE
State : CA
Zip : 91901-2113
Country : US
Telephone Number : 209-247-9207
Fax Number :
Provider Business Practice Location Address
First Line : 4141 N BLACKSTONE AVE
Second Line :
City : FRESNO
State : CA
Zip : 93726-3808
Country : US
Telephone Number : 559-365-1717
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2011
Last Update Date : 04/15/2024

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