Healthcare Provider Details

I. General information

NPI: 1326016627
Provider Name (Legal Business Name): NANCY LYNN WADE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR STE 130
GLENDALE CA
91206-4140
US

IV. Provider business mailing address

1560 E CHEVY CHASE DR STE 130
GLENDALE CA
91206-4140
US

V. Phone/Fax

Practice location:
  • Phone: 818-240-0340
  • Fax:
Mailing address:
  • Phone: 818-240-0340
  • Fax: 818-545-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY9965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: