Healthcare Provider Details

I. General information

NPI: 1366910721
Provider Name (Legal Business Name): MARISSA WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1558 E BOULEVARD STE A
KOKOMO IN
46902-2587
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 765-252-0530
  • Fax: 317-520-8200
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68063
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: