Provider Demographics
NPI:1316586803
Name:WELLS, CLARISSA (MED)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17114 MONTHAVEN PARK PL APT 17114
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-7076
Mailing Address - Country:US
Mailing Address - Phone:865-696-5138
Mailing Address - Fax:
Practice Address - Street 1:100 COUNTRY CLUB DR STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-4376
Practice Address - Country:US
Practice Address - Phone:615-348-5806
Practice Address - Fax:615-285-8130
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003685101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional