=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245806090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WADE LUQUET MSW, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2021
-----------------------------------------------------
Last Update Date | 06/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S MAIN ST STE 2B
-----------------------------------------------------
City | NORTH WALES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19454-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-699-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 842 PATTERSON DR
-----------------------------------------------------
City | LANSDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19446-5432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-390-6321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW017731
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------