Provider Demographics
NPI:1932680998
Name:WELLS, BENJAMIN MICHAEL
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 DOUGLAS DR STE 21F
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8980
Mailing Address - Country:US
Mailing Address - Phone:231-668-4909
Mailing Address - Fax:231-943-1334
Practice Address - Street 1:1363 DOUGLAS DR STE 21F
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-8980
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:231-943-1334
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst