Healthcare Provider Details

I. General information

NPI: 1760424634
Provider Name (Legal Business Name): WADE D WILLIAMS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S SHARON AMITY RD SUITE 105
CHARLOTTE NC
28211-2824
US

IV. Provider business mailing address

517 S SHARON AMITY RD SUITE 105
CHARLOTTE NC
28211-2824
US

V. Phone/Fax

Practice location:
  • Phone: 704-362-1555
  • Fax: 704-362-0023
Mailing address:
  • Phone: 704-362-1555
  • Fax: 704-362-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: