Basic Information
Provider Information
NPI: 1003001504
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WELLS
FirstName: SHIRLEY
MiddleName: ANN
NamePrefix: MS.
NameSuffix:  
Credential: M.ED., LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7511 WARWICK DR
Address2:  
City: SAINT LOUIS
State: MO
PostalCode: 631212436
CountryCode: US
TelephoneNumber: 3143827997
FaxNumber: 3143827997
Practice Location
Address1: 3309 S. KINGSHIGHWAY BLVD
Address2: FAMILY RESOURCE CENTER
City: SAINT LOUIS
State: MO
PostalCode: 63139
CountryCode: US
TelephoneNumber: 3145341204
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/08/2007
LastUpdateDate: 09/21/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X2002013515MOY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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