Provider Demographics
NPI:1780885772
Name:WELLES, NYDIA LELIA (PHD)
Entity type:Individual
Prefix:DR
First Name:NYDIA
Middle Name:LELIA
Last Name:WELLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NYDIA
Other - Middle Name:LELIA
Other - Last Name:CANOVAS WELLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:4019 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1773
Mailing Address - Country:US
Mailing Address - Phone:847-676-3440
Mailing Address - Fax:847-676-3486
Practice Address - Street 1:4019 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1773
Practice Address - Country:US
Practice Address - Phone:847-676-3440
Practice Address - Fax:847-676-3486
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01673394OtherBLUE CROSS AND BLUE SHIEL
IL632290Medicare ID - Type Unspecified