Provider Demographics
NPI:1144049636
Name:WELLS, EVANGELINE HELEN
Entity type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:HELEN
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:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12842-0030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 SCHOOL LN
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:NY
Practice Address - Zip Code:12847-7759
Practice Address - Country:US
Practice Address - Phone:518-624-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120525-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker