Basic Information
| Provider Information | |||||||||
| NPI: | 1982652368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPADE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 AUSTIN ST | ||||||||
| Address2: | |||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077127759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327623579 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 94 STEVENS RD | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087551490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329141100 | ||||||||
| FaxNumber: | 7327973830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05365500 | NJ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW7668 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | Z105X | 01 | FL | BCBS PROVIDER NUMBER | OTHER |