Provider Demographics
NPI:1114134046
Name:WELLS, TRACY (CADC-II)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13803 PINKARD WAY UNIT 14
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-1964
Mailing Address - Country:US
Mailing Address - Phone:619-993-8716
Mailing Address - Fax:
Practice Address - Street 1:4690 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3031
Practice Address - Country:US
Practice Address - Phone:858-277-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA2002205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)