Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | CC4517 | ME |
N | 101YP2500X | Professional Counselor | XL4067 | ME |
NPI | 1003152505 |
---|---|
Provider Name | Ryan David Wells |
First Address | Bangor, ME 04401 |
Second Address | Waterville, ME 04901-6100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2013 |
Last Update Date | 29/07/2015 |