Provider Demographics
NPI:1831675529
Name:WELLS, JOHN W
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:W
Other - Last Name:WELLS
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2630 HARMONY PATH
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8298
Mailing Address - Country:US
Mailing Address - Phone:269-759-8750
Mailing Address - Fax:
Practice Address - Street 1:777 RIVERVIEW DR STE 102
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5065
Practice Address - Country:US
Practice Address - Phone:269-759-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012511103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical