Provider Demographics
NPI:1033293204
Name:WELLS, TIMOTHY L (LPC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:WELLS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2032
Mailing Address - Country:US
Mailing Address - Phone:417-667-9697
Mailing Address - Fax:417-667-5737
Practice Address - Street 1:200 S ALMA ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3945
Practice Address - Country:US
Practice Address - Phone:417-667-9697
Practice Address - Fax:417-667-5737
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002368CS101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25896032OtherBCBS OF KANSAS CITY
MO499675825Medicaid