Healthcare Provider Details

I. General information

NPI: 1003152505
Provider Name (Legal Business Name): RYAN DAVID WELLS LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 COLLEGE AVE SUITE 206
WATERVILLE ME
04901-6100
US

IV. Provider business mailing address

157 PARK ST. SUITE 5
BANGOR ME
04401
US

V. Phone/Fax

Practice location:
  • Phone: 207-680-2065
  • Fax: 207-680-2068
Mailing address:
  • Phone: 207-992-0410
  • Fax: 207-992-0414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC4517
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL4067
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: