Provider Demographics
NPI:1659884443
Name:WELLS, KASEY RENAY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:RENAY
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 1:701 DEVONSHIRE DR STE B16-18
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7337
Mailing Address - Country:US
Mailing Address - Phone:217-531-2360
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR STE B16-18
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7337
Practice Address - Country:US
Practice Address - Phone:217-531-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health