Provider Demographics
NPI:1144053331
Name:WADE, DENSIL JR
Entity type:Individual
Prefix:
First Name:DENSIL
Middle Name:
Last Name:WADE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 W MARTIN LUTHER KING JR BLVD APT 297
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-5566
Mailing Address - Country:US
Mailing Address - Phone:213-524-2027
Mailing Address - Fax:
Practice Address - Street 1:4611 W MARTIN LUTHER KING JR BLVD APT 297
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-5566
Practice Address - Country:US
Practice Address - Phone:213-524-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76067159106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician