Provider Demographics
NPI:1447897806
Name:PETERSON, WADE CHRISTIAN (MA, LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:CHRISTIAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16516 PORTERFIELD LANE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4144 N CENTRAL EXPY STE 850
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3226
Practice Address - Country:US
Practice Address - Phone:972-865-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health