Healthcare Provider Details

I. General information

NPI: 1396957882
Provider Name (Legal Business Name): ERIN J WADE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 S BELL SCHOOL RD STE 7
ROCKFORD IL
61108-1405
US

IV. Provider business mailing address

PO BOX 229
SUBLETTE IL
61367-0229
US

V. Phone/Fax

Practice location:
  • Phone: 815-627-0641
  • Fax:
Mailing address:
  • Phone: 815-627-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071-007297
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number269565
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number282-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: