MEDICARE: MR. GEORGE WELLS PETRAS L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0701003613	VA
2	101YM0800X	Mental Health Counselor	LPC004835	GA

General Provider Information

NPI Number	:	1144496092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE WELLS PETRAS L.P.C.

Provider Business Mailing Address
First Line	:	3675 LAWRENCEVILLE SUWANEE RD
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-2328
Country	:	US
Telephone Number	:	706-424-6674
Fax Number	:

Provider Business Practice Location Address
First Line	:	3675 LAWRENCEVILLE SUWANEE RD
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-2328
Country	:	US
Telephone Number	:	706-424-6674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2008
Last Update Date	:	05/01/2008

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