Provider Demographics
NPI:1144512328
Name:WELLS, DOUGLAS DAYNE (MA, LPP)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:DAYNE
Last Name:WELLS
Suffix:
Gender:M
Credentials:MA, LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3242
Mailing Address - Country:US
Mailing Address - Phone:270-442-8785
Mailing Address - Fax:
Practice Address - Street 1:2204 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3242
Practice Address - Country:US
Practice Address - Phone:270-442-8785
Practice Address - Fax:270-443-1784
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist