Provider Demographics
NPI:1497900153
Name:WELLS, GREGORY CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CHARLES
Last Name:WELLS
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 1:4257 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2409
Mailing Address - Country:US
Mailing Address - Phone:415-874-9226
Mailing Address - Fax:415-874-9448
Practice Address - Street 1:4257 18TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-2409
Practice Address - Country:US
Practice Address - Phone:415-874-9226
Practice Address - Fax:415-874-9448
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-22
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1111103TC0700X, 103TS0200X, 103TC2200X
CA23440103TC0700X, 103T00000X, 103TC2200X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral