Provider Demographics
NPI:1174887483
Name:WADE, LEE TYSON (LPC)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:TYSON
Last Name:WADE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 BAYTREE ROAD
Mailing Address - Street 2:#8
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-244-5533
Mailing Address - Fax:229-253-9066
Practice Address - Street 1:1205 BAYTREE ROAD
Practice Address - Street 2:#8
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-244-5533
Practice Address - Fax:229-253-9066
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional