Healthcare Provider Details

I. General information

NPI: 1619189446
Provider Name (Legal Business Name): IRIS WADE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 EXECUTIVE CENTER DR SUITE 303
LITTLE ROCK AR
72211-4354
US

IV. Provider business mailing address

10810 EXECUTIVE CENTER DR SUITE 303
LITTLE ROCK AR
72211-4354
US

V. Phone/Fax

Practice location:
  • Phone: 501-312-7578
  • Fax: 501-312-7577
Mailing address:
  • Phone: 501-312-7578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2308
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: