Healthcare Provider Details

I. General information

NPI: 1215076476
Provider Name (Legal Business Name): MICHAEL DEAN WADE MS, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 W POWELL BLVD
GRESHAM OR
97030-7050
US

IV. Provider business mailing address

343 W POWELL BLVD
GRESHAM OR
97030-7050
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-9171
  • Fax: 503-667-9072
Mailing address:
  • Phone: 503-666-9171
  • Fax: 503-667-9072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number7803
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: