Provider Demographics
NPI:1265737951
Name:WADE, SHANITA
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE A100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8404
Practice Address - Country:US
Practice Address - Phone:517-798-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017983101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679594832OtherBLUE CROSS BLUE SHIELD
MI1679594832Medicaid
MI1679594832OtherUNITED BEHAVIORAL HEALTH (UBH)