Provider Demographics
NPI:1134691264
Name:WELLS, GEORGETTE EUGENIA
Entity Type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:EUGENIA
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GEORGETTE
Other - Middle Name:EUGENUA
Other - Last Name:MILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:4757 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4732
Practice Address - Country:US
Practice Address - Phone:414-358-4145
Practice Address - Fax:414-358-5005
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18197OtherLICENSE