MEDICARE: HOLLY WADE LCSW LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1770059768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLY WADE LCSW LLC

Provider Business Mailing Address
First Line	:	151 INTEGRA VISTAS DR APT 306
Second Line	:
City	:	HIXSON
State	:	TN
Zip	:	37343-5378
Country	:	US
Telephone Number	:	203-918-0336
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 DAYTON BLVD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6415
Country	:	US
Telephone Number	:	203-918-0336
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	HOLLY E WADE
Credential	:	LCSW
Telephone Number	:	203-918-0336

Provider Enumeration Date	:	10/17/2018
Last Update Date	:	10/17/2018

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