Provider Demographics
NPI:1629632575
Name:WELLS, MELISSA TACY
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:TACY
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 E 920 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4328
Mailing Address - Country:US
Mailing Address - Phone:801-615-3160
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2801
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician