Provider Demographics
NPI:1588007256
Name:WELLS, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7887 DITTER RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:DITTMER
Mailing Address - State:MO
Mailing Address - Zip Code:63023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7887 DITTER RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:DITTMER
Practice Address - State:MO
Practice Address - Zip Code:63023
Practice Address - Country:US
Practice Address - Phone:636-274-5327
Practice Address - Fax:636-274-0413
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008023537235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist