MEDICARE: PAULETTE MARIE WELLS LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	876	LA

General Provider Information

NPI Number	:	1396172029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULETTE MARIE WELLS LAC

Provider Business Mailing Address
First Line	:	4615 GOVERNMENT ST
Second Line	:	BUILDING 2
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-5922
Country	:	US
Telephone Number	:	225-925-4282
Fax Number	:	225-925-1987

Provider Business Practice Location Address
First Line	:	2455 WOODDALE BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70805-7569
Country	:	US
Telephone Number	:	225-922-3169
Fax Number	:	225-922-3225

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

Provider Enumeration Date	:	09/26/2013
Last Update Date	:	09/26/2013

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