Provider Demographics
NPI:1730234873
Name:WELLS, PHILIP A (MSN, LCSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:WELLS
Suffix:
Gender:M
Credentials:MSN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W STATE ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1455
Mailing Address - Country:US
Mailing Address - Phone:815-895-1044
Mailing Address - Fax:815-895-1054
Practice Address - Street 1:407 W STATE ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1455
Practice Address - Country:US
Practice Address - Phone:815-895-1044
Practice Address - Fax:815-895-1054
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical