Provider Demographics
NPI:1467432450
Name:WELLBORN, WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WELLBORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 JEFFERSON ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-526-1364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-002556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7709129Medicaid
VA680010448Medicare PIN
VAS50703Medicare UPIN
VA680001178Medicare PIN