MEDICARE: MRS. STEPHANIE LYNN WADE MFT

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	106H00000X	Marriage & Family Therapist	MFC 43104	CA

General Provider Information

NPI Number	:	1477754935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE LYNN WADE MFT

Provider Business Mailing Address
First Line	:	826 ROSE DR
Second Line	:
City	:	BENICIA
State	:	CA
Zip	:	94510-3601
Country	:	US
Telephone Number	:	707-372-0227
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 MISSOURI ST STE 203E
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-6065
Country	:	US
Telephone Number	:	707-425-9670
Fax Number	:	707-425-9880

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

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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