Provider Demographics
NPI:1376212829
Name:WELLS, KATRINA DIANE MICHELLE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:DIANE MICHELLE
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 1:2835 PRADO
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6762
Mailing Address - Country:US
Mailing Address - Phone:817-676-8673
Mailing Address - Fax:
Practice Address - Street 1:285 UPTOWN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3526
Practice Address - Country:US
Practice Address - Phone:972-291-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19515235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist