Provider Demographics
NPI:1770991135
Name:WELLS, STACEY
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
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 1:57168 SOMERTON HWY
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713-9723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1069
Practice Address - Country:US
Practice Address - Phone:740-425-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH.8643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist