Provider Demographics
NPI:1790709566
Name:WELLS, NNEKA (OTR/L)
Entity Type:Individual
Prefix:
First Name:NNEKA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 BEAUBIEN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:485-247-2742
Mailing Address - Fax:248-457-1524
Practice Address - Street 1:1060 W STATE ROAD 434
Practice Address - Street 2:SUITE 108
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4919
Practice Address - Country:US
Practice Address - Phone:407-260-0551
Practice Address - Fax:407-265-9590
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010275225X00000X
FLOT 11334225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889516300Medicaid