MEDICARE: DEIANDRA SHANEYCE WADE LPCA

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
1	101YM0800X	Mental Health Counselor	A13096	NC

General Provider Information

NPI Number	:	1386141349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIANDRA SHANEYCE WADE LPCA

Provider Business Mailing Address
First Line	:	1311 ELMER ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5801
Country	:	US
Telephone Number	:	336-324-6333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3409 W WENDOVER AVE STE I
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1579
Country	:	US
Telephone Number	:	336-897-2375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	04/06/2018

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