Provider Demographics
NPI:1952975336
Name:RADECKE, WELLSLEY BRIELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:WELLSLEY
Middle Name:BRIELLE
Last Name:RADECKE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HARBRIDGE MNR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5830
Mailing Address - Country:US
Mailing Address - Phone:716-574-3311
Mailing Address - Fax:
Practice Address - Street 1:1031 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1022
Practice Address - Country:US
Practice Address - Phone:315-732-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001404106H00000X
NY025317-01103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist