Provider Demographics
NPI:1396438735
Name:WELLS, REGINA S
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:S
Last Name:WELLS
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 1:25113 S CHENNAULT AVE
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-9019
Mailing Address - Country:US
Mailing Address - Phone:708-259-6032
Mailing Address - Fax:
Practice Address - Street 1:19624 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2077
Practice Address - Country:US
Practice Address - Phone:872-225-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109837104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker