Provider Demographics
NPI:1255465639
Name:WELLS, DOUGLAS ROY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ROY
Last Name:WELLS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 WARNER AVE # B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4916
Mailing Address - Country:US
Mailing Address - Phone:208-746-2948
Mailing Address - Fax:
Practice Address - Street 1:307 19TH ST STE A3
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2086
Practice Address - Country:US
Practice Address - Phone:208-746-2948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCSW511101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1693377Medicare ID - Type UnspecifiedMEDICARE