Provider Demographics
NPI:1104717511
Name:WELLS, DESTINEE NICOLE
Entity type:Individual
Prefix:
First Name:DESTINEE
Middle Name:NICOLE
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 1:1740 RIDGE AVE STE LL15A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE STE LL15A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5919
Practice Address - Country:US
Practice Address - Phone:312-877-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health