Provider Demographics
NPI:1831127745
Name:WELLS, AMY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1718
Mailing Address - Country:US
Mailing Address - Phone:229-333-0300
Mailing Address - Fax:229-333-0306
Practice Address - Street 1:2914 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1718
Practice Address - Country:US
Practice Address - Phone:229-333-0300
Practice Address - Fax:229-333-0306
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0030361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFMQMedicare ID - Type Unspecified