Provider Demographics
NPI:1023708138
Name:WADE, NATHAN TUCKER
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:TUCKER
Last Name:WADE
Suffix:
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 1:4655 DORIS CIR S
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-2301
Mailing Address - Country:US
Mailing Address - Phone:901-626-3403
Mailing Address - Fax:
Practice Address - Street 1:6363 POPLAR AVE STE 404
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4831
Practice Address - Country:US
Practice Address - Phone:901-626-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor