Provider Demographics
NPI:1649524521
Name:WELLS, ROBERT G (MA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:G
Last Name:WELLS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:R
Other - Middle Name:GREG
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:7167 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8001
Mailing Address - Country:US
Mailing Address - Phone:817-601-5365
Mailing Address - Fax:
Practice Address - Street 1:7167 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8001
Practice Address - Country:US
Practice Address - Phone:817-601-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20325101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional