Provider Demographics
NPI:1053741173
Name:WADE, MICHAEL KEITH (LPC-S)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:WADE
Suffix:
Gender:M
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 E YANDELL DR STE 9
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3517
Mailing Address - Country:US
Mailing Address - Phone:915-277-0300
Mailing Address - Fax:
Practice Address - Street 1:2104 E YANDELL DR STE 9
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3517
Practice Address - Country:US
Practice Address - Phone:915-277-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68877101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health