Healthcare Provider Details

I. General information

NPI: 1629165188
Provider Name (Legal Business Name): TERESA WADE L.M.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N POPLAR AVE
WICHITA KS
67214-4529
US

IV. Provider business mailing address

620 CONESTOGA RD
MAIZE KS
67101-9306
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-6671
  • Fax: 316-686-1094
Mailing address:
  • Phone: 316-722-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number199
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0369
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: