Provider Demographics
NPI:1538720057
Name:WELLUS LLC
Entity type:Organization
Organization Name:WELLUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMELLA
Authorized Official - Middle Name:CHARLENE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:267-307-9700
Mailing Address - Street 1:7973 THOURON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2520
Mailing Address - Country:US
Mailing Address - Phone:267-237-0042
Mailing Address - Fax:267-907-1120
Practice Address - Street 1:505 OLD YORK ROAD
Practice Address - Street 2:SUITE 107
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-1904
Practice Address - Country:US
Practice Address - Phone:267-307-9700
Practice Address - Fax:267-307-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health