Provider Demographics
NPI:1730263609
Name:WELLS, MARY A (LBSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:WELLS
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8840 WINN RD
Mailing Address - Street 2:
Mailing Address - City:BROWN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48416-8508
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:
Practice Address - Street 1:1570 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1154
Practice Address - Country:US
Practice Address - Phone:810-667-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085190104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705242 TYPE 21Medicaid