Provider Demographics
NPI:1649930645
Name:WELLS, TAIJUANA (MA, LPC)
Entity type:Individual
Prefix:
First Name:TAIJUANA
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MOONLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63135-1448
Mailing Address - Country:US
Mailing Address - Phone:314-338-1896
Mailing Address - Fax:
Practice Address - Street 1:737 DUNN RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1740
Practice Address - Country:US
Practice Address - Phone:314-230-0362
Practice Address - Fax:314-731-4433
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-19
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021042219101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490106035Medicaid