Provider Demographics
NPI:1679340665
Name:WADE, LUTISHA (MA, LPC-A)
Entity type:Individual
Prefix:
First Name:LUTISHA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MA, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 HIGHWAY 160 W STE 105268
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1646 HIGHWAY 160 W STE 105268
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8037
Practice Address - Country:US
Practice Address - Phone:803-784-8754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8719101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health