Provider Demographics
NPI:1457656019
Name:WELLS, SAMUEL DAERONNE JR (AAC)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DAERONNE
Last Name:WELLS
Suffix:JR
Gender:M
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:SOUND MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:1720 E OLIVE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3386
Practice Address - Country:US
Practice Address - Phone:206-331-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60324035101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health