Provider Demographics
NPI:1871387878
Name:WAHL ADAME, JUSTIN DEAN (SAC-IT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEAN
Last Name:WAHL ADAME
Suffix:
Gender:
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S IRISH RD APT 7
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1273
Mailing Address - Country:US
Mailing Address - Phone:951-218-0403
Mailing Address - Fax:
Practice Address - Street 1:2801 CALUMET DRIVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083
Practice Address - Country:US
Practice Address - Phone:951-218-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20789-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)