Healthcare Provider Details

I. General information

NPI: 1174594048
Provider Name (Legal Business Name): WESLEY M. EADES PH.D., LPC, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WESLEY M. EADES PH.D.

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 AUSTIN AVE SUITE 501
WACO TX
76701-1902
US

IV. Provider business mailing address

PO BOX 2421
WACO TX
76703-2421
US

V. Phone/Fax

Practice location:
  • Phone: 254-498-7176
  • Fax: 254-230-4401
Mailing address:
  • Phone: 254-498-7176
  • Fax: 254-230-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11800
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3445
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: