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General NPI Number Information
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NPI Number | 1639483688
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Entity Type | Individual
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Provider Name | MICHAEL BRENT WADE JR. LMHC
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Gender | Male
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Dates
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Enumeration Date | 08/02/2010
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Last Update Date | 08/13/2015
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Provider Practice Location Address
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Address Line | 4711 US HIGHWAY 17 BLDG C SUITE 4
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-8233
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Country | US
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Telephone | 904-465-1275
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Fax |
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Provider Business Mailing Address
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Address Line | 308 MARISCO WAY
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City | JACKSONVILLE
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State | FL
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Zip | 32220-4608
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Country | US
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Telephone | 904-465-1275
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | MH 11491
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License Number State | FL
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