Provider Demographics
NPI:1497313605
Name:WELLS, PHYLLIS W (LPC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:W
Last Name:WELLS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16607 BLANCO RD STE 1404
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1945
Mailing Address - Country:US
Mailing Address - Phone:210-209-0642
Mailing Address - Fax:855-357-8282
Practice Address - Street 1:16607 BLANCO RD STE 1404
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1945
Practice Address - Country:US
Practice Address - Phone:210-209-0642
Practice Address - Fax:855-357-8282
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional