Provider Demographics
NPI:1093931099
Name:WELLS, PHYLLIS E (LMFT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:E
Last Name:WELLS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 E COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-2023
Mailing Address - Country:US
Mailing Address - Phone:520-836-0440
Mailing Address - Fax:520-836-0924
Practice Address - Street 1:635 E COTTONWOOD LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-2023
Practice Address - Country:US
Practice Address - Phone:520-836-0440
Practice Address - Fax:520-836-0924
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT0046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLMFT0046OtherSTATE LICENSE