Healthcare Provider Details

I. General information

NPI: 1871962845
Provider Name (Legal Business Name): DESIREE WADE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N PINE ST
SAINT ANTHONY ID
83445-5353
US

IV. Provider business mailing address

316 N PINE ST
SAINT ANTHONY ID
83445-5353
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-0926
  • Fax:
Mailing address:
  • Phone: 208-313-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-5893
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: