Provider Demographics
NPI:1710195540
Name:WELLS, TERESA (PHD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:TALMAGE
Mailing Address - State:CA
Mailing Address - Zip Code:95481-0268
Mailing Address - Country:US
Mailing Address - Phone:707-462-6801
Mailing Address - Fax:
Practice Address - Street 1:518 S SCHOOL ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5479
Practice Address - Country:US
Practice Address - Phone:707-462-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical