Provider Demographics
NPI:1265861819
Name:WELLS, MARISSA JENAI (MA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JENAI
Last Name:WELLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10720 CARMEL COMMONS BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3785
Mailing Address - Country:US
Mailing Address - Phone:704-916-9192
Mailing Address - Fax:
Practice Address - Street 1:10720 CARMEL COMMONS BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3785
Practice Address - Country:US
Practice Address - Phone:704-916-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist