Provider Demographics
NPI:1114048436
Name:WELLS, WENDY ALTHEA (MSPT)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ALTHEA
Last Name:WELLS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:NORTH CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:12853-0500
Mailing Address - Country:US
Mailing Address - Phone:518-251-2447
Mailing Address - Fax:518-251-4207
Practice Address - Street 1:112 SKI BOWL ROAD
Practice Address - Street 2:
Practice Address - City:NORTH CREEK
Practice Address - State:NY
Practice Address - Zip Code:12853-0500
Practice Address - Country:US
Practice Address - Phone:518-251-2447
Practice Address - Fax:518-251-4207
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308943Medicaid
NY00308943Medicaid