MEDICARE: MRS. SUSAN Y WADE LCSW

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	35359	TX

General Provider Information

NPI Number	:	1518073311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN Y WADE LCSW

Provider Business Mailing Address
First Line	:	1624 ENDERLY PL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4120
Country	:	US
Telephone Number	:	817-207-0042
Fax Number	:	817-887-4649

Provider Business Practice Location Address
First Line	:	1624 ENDERLY PL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4120
Country	:	US
Telephone Number	:	817-207-0042
Fax Number	:	817-887-4649

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/13/2016

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