Provider Demographics
NPI:1871675884
Name:WELLMAN, LAWRENCE E (EDD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:E
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 N ACADEMY BLVD
Mailing Address - Street 2:160
Mailing Address - City:COSPS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5176
Mailing Address - Country:US
Mailing Address - Phone:719-597-5959
Mailing Address - Fax:719-597-0166
Practice Address - Street 1:3208 N ACADEMY BLVD
Practice Address - Street 2:160
Practice Address - City:COSPS
Practice Address - State:CO
Practice Address - Zip Code:80917-5176
Practice Address - Country:US
Practice Address - Phone:719-597-5959
Practice Address - Fax:719-597-0166
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1084103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91876Medicare ID - Type Unspecified