Provider Demographics
NPI:1639696610
Name:WELLS, DEIDRA R (LMFT)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:R
Last Name:WELLS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DEIDRA
Other - Middle Name:
Other - Last Name:KOSTELAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:8253 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:760-953-7625
Mailing Address - Fax:
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:442-327-9311
Practice Address - Fax:442-327-9311
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72411106H00000X
CA119415106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist