Provider Demographics
NPI:1568568376
Name:WELLS, MARY J (PHD LCP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:WELLS
Suffix:
Gender:F
Credentials:PHD LCP
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:11958 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233
Practice Address - Country:US
Practice Address - Phone:804-360-4669
Practice Address - Fax:804-364-6521
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001817103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA198317000OtherMAGELLAN
VA31705OtherVALUE OPTIONS
VA356101OtherPHCS
VA4529892OtherAETNA
VA190033OtherCOMPSYCH
VA082546OtherSENTARA BEHAVIORAL
VA191723OtherHEALTHKEEPERS
VA341259OtherUBH
VA381756OtherANTHEM
VA611681OtherOPTIMUM CHOICE