Provider Demographics
NPI:1851910236
Name:WELLON-DAMES, OLETHA G
Entity Type:Individual
Prefix:MRS
First Name:OLETHA
Middle Name:G
Last Name:WELLON-DAMES
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 1:139 BOB THOMAS CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3096
Mailing Address - Country:US
Mailing Address - Phone:407-820-4133
Mailing Address - Fax:
Practice Address - Street 1:139 BOB THOMAS CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-3096
Practice Address - Country:US
Practice Address - Phone:407-820-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00125101YP1600X
FLD520172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral