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NPI Code Detail

MEDICARE: CORETTA WADE

MEDICARE: CORETTA WADE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker
2390200000XStudent in an Organized Health Care Education/Training Program

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1051805016OTHERFLDRIVE LICENSE

General Provider Information

NPI Number : 1215456470
Entity Type Code : Individual
Provider Name (Legal Business Name) : CORETTA WADE
Provider Business Mailing Address
First Line : 270 CARPENTER DR STE 400
Second Line :
City : SANDY SPRINGS
State : GA
Zip : 30328-4933
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 270 CARPENTER DR STE 400
Second Line :
City : SANDY SPRINGS
State : GA
Zip : 30328-4933
Country : US
Telephone Number : 678-851-5638
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/19/2017
Last Update Date : 06/16/2018

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Directions to “ CORETTA WADE ” Practice Location

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