Healthcare Provider Details

I. General information

NPI: 1104515873
Provider Name (Legal Business Name): RAQUEL WELLS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PLEASANT HILL AVE N STE 200Q
SEBASTOPOL CA
95472-3167
US

IV. Provider business mailing address

200 S MAIN ST # 100-535
SEBASTOPOL CA
95472-4284
US

V. Phone/Fax

Practice location:
  • Phone: 415-294-0032
  • Fax:
Mailing address:
  • Phone: 707-503-0569
  • Fax: 707-261-1258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: RAQUEL WELLS
Title or Position: DIRECTOR
Credential: LCSW
Phone: 415-535-8660