Provider Demographics
NPI:1396786349
Name:WELLER, LOUISE ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:ANNE
Last Name:WELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1250
Mailing Address - Country:US
Mailing Address - Phone:734-335-0028
Mailing Address - Fax:
Practice Address - Street 1:340 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1250
Practice Address - Country:US
Practice Address - Phone:734-335-0028
Practice Address - Fax:734-335-3931
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016136-1103TC0700X
MI6301016196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301016196OtherLICENSE TO PRACTICE AS PSYCHOLOGIST
NY016136OtherPSYCHOLOGIST STATE LICENS