MEDICARE: NICHOLAS WADE CDCA

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	324500000X	Substance Abuse Rehabilitation Facility		OH
2	175T00000X	Peer Specialist	0001998	OH

General Provider Information

NPI Number	:	1588104012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS WADE CDCA

Provider Business Mailing Address
First Line	:	5760 PATRIOT BLVD
Second Line	:
City	:	AUSTINTOWN
State	:	OH
Zip	:	44515-1170
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5760 PATRIOT BLVD
Second Line	:
City	:	AUSTINTOWN
State	:	OH
Zip	:	44515-1170
Country	:	US
Telephone Number	:	330-953-0243
Fax Number	:

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

Provider Enumeration Date	:	03/02/2017
Last Update Date	:	09/21/2020

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Directions to “ NICHOLAS WADE CDCA” Practice Location

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