Provider Demographics
NPI:1841493434
Name:WELLS, RICHARD LEE
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEE
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4449
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-4449
Mailing Address - Country:US
Mailing Address - Phone:573-889-9534
Mailing Address - Fax:
Practice Address - Street 1:120 BROOKS ST APT 17
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-8031
Practice Address - Country:US
Practice Address - Phone:573-889-9534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-09
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002020616101YP2500X
101YP1600X, 171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498829100Medicaid