Provider Demographics
NPI:1003152505
Name:WELLS, RYAN DAVID (LCPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:WELLS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 PARK ST.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-992-0410
Mailing Address - Fax:207-992-0414
Practice Address - Street 1:32 COLLEGE AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6100
Practice Address - Country:US
Practice Address - Phone:207-680-2065
Practice Address - Fax:207-680-2068
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4517101YP2500X
MEXL4067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional