Healthcare Provider Details

I. General information

NPI: 1013033208
Provider Name (Legal Business Name): MATTHEW EDWARD WELLS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SPRINGBROOK DR
BIDDEFORD ME
04005-9443
US

IV. Provider business mailing address

78 ATLANTIC PL
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-282-1500
  • Fax: 207-282-2581
Mailing address:
  • Phone: 207-661-6654
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126102
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC15155
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: