Provider Demographics
NPI:1619215274
Name:WELLS, TANESHA (MS, LLMFT)
Entity Type:Individual
Prefix:
First Name:TANESHA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:MS, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 WHITCOMB ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 S MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4951
Practice Address - Country:US
Practice Address - Phone:734-641-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006546106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist