Provider Demographics
NPI:1730575937
Name:WELLS, MAKENZIE
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
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 1:435 HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:WARE SHOALS
Mailing Address - State:SC
Mailing Address - Zip Code:29692-2830
Mailing Address - Country:US
Mailing Address - Phone:864-992-1396
Mailing Address - Fax:
Practice Address - Street 1:104 MAXWELL AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2641
Practice Address - Country:US
Practice Address - Phone:864-229-7529
Practice Address - Fax:864-229-7530
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2846225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant