Provider Demographics
NPI:1356094395
Name:WELLS, ELICIA NICOLE
Entity Type:Individual
Prefix:MISS
First Name:ELICIA
Middle Name:NICOLE
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 S RACCOON RD APT B21
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3650
Mailing Address - Country:US
Mailing Address - Phone:804-912-3626
Mailing Address - Fax:
Practice Address - Street 1:5211 MAHONING AVE STE 370
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1853
Practice Address - Country:US
Practice Address - Phone:330-792-4724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2202329-TRNE1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340685251Medicaid