Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 13701 | NC |
N | 225C00000X | Rehabilitation Counselor | 00304135 | NC |
NPI | 1174017321 |
---|---|
Provider Name | Amanda Wade |
First Address | Charlotte, NC 28204-0044 |
Second Address | Concord, NC 28025-2979 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2018 |
Last Update Date | 20/06/2018 |