Provider Demographics
NPI:1861159154
Name:WADE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 PUTTENHAM WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3540
Mailing Address - Country:US
Mailing Address - Phone:909-963-4731
Mailing Address - Fax:
Practice Address - Street 1:3164 PUTTENHAM WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3540
Practice Address - Country:US
Practice Address - Phone:650-542-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist