=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457400459
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTELLE B. WADE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 03/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 E 55TH ST SUITE 9B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-935-1213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7654 FDR STATION
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10150-7654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-935-1213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 4143
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------