Healthcare Provider Details

I. General information

NPI: 1740577881
Provider Name (Legal Business Name): MS. YVETTE DARLENE WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE STE 5
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

6266 BETH PAGE DR
FONTANA CA
92336-1229
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2400
  • Fax: 951-509-2405
Mailing address:
  • Phone: 213-200-0535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number89452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: