MEDICARE: CRYSTINA WELLS

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	101YP2500X	Professional Counselor	12918791-6004	UT
2	101YP2500X	Professional Counselor	180012737	IL

General Provider Information

NPI Number	:	1477118974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTINA WELLS

Provider Business Mailing Address
First Line	:	1602 W WALNUT ST
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-1310
Country	:	US
Telephone Number	:	618-364-2504
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 W WALNUT ST
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-1310
Country	:	US
Telephone Number	:	618-364-2504
Fax Number	:

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

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	04/02/2026

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Directions to “ CRYSTINA WELLS ” Practice Location

Language	Start Address	Practice Location

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