Basic Information
| Provider Information | |||||||||
| NPI: | 1003152505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 PARK ST. | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079920410 | ||||||||
| FaxNumber: | 2079920414 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 COLLEGE AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049016100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076802065 | ||||||||
| FaxNumber: | 2076802068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC4517 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | XL4067 | ME | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.