Provider Demographics
NPI:1295358026
Name:WELLS, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 OLD QUARRY RD APT 10
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1426
Mailing Address - Country:US
Mailing Address - Phone:510-207-6286
Mailing Address - Fax:
Practice Address - Street 1:2311 LOVERIDGE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5117
Practice Address - Country:US
Practice Address - Phone:888-678-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117619106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty