MEDICARE: DR. ERIN J WADE PH.D.

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
1	103TM1800X	Intellectual & Developmental Disabilities Psychologist	071-007297	IL
2	103K00000X	Behavior Analyst	269565	KY
3	103K00000X	Behavior Analyst	282-140	WI

General Provider Information

NPI Number	:	1396957882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIN J WADE PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 229
Second Line	:
City	:	SUBLETTE
State	:	IL
Zip	:	61367-0229
Country	:	US
Telephone Number	:	815-627-0641
Fax Number	:

Provider Business Practice Location Address
First Line	:	1437 S BELL SCHOOL RD STE 7
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-1405
Country	:	US
Telephone Number	:	815-627-0641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	11/03/2021

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