Provider Demographics
NPI:1952772410
Name:WELLS, WILLIE JOHNATHAN (LPC)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:JOHNATHAN
Last Name:WELLS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4233
Mailing Address - Country:US
Mailing Address - Phone:622-253-8040
Mailing Address - Fax:662-470-5984
Practice Address - Street 1:6857 COBBLESTONE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9312
Practice Address - Country:US
Practice Address - Phone:662-253-8040
Practice Address - Fax:662-470-5984
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023618Medicaid
MS04539260Medicaid