Basic Information
| Provider Information | |||||||||
| NPI: | 1164991931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1536 N BOULDER HWY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890114120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025588600 | ||||||||
| FaxNumber: | 7025588700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1785 E SAHARA AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891043759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022528342 | ||||||||
| FaxNumber: | 7022528349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | AII054680418 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 02578-I | NV | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.