Healthcare Provider Details

I. General information

NPI: 1144164161
Provider Name (Legal Business Name): SUSAN MARIE WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2026
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MONTGOMERY BLVD NE STE D&F
ALBUQUERQUE NM
87111-3816
US

IV. Provider business mailing address

11229 MALAGUENA LN NE
ALBUQUERQUE NM
87111-6829
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-6155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: