Healthcare Provider Details

I. General information

NPI: 1760934335
Provider Name (Legal Business Name): BETHANY WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 LIVERNOIS ST
FERNDALE MI
48220-2306
US

IV. Provider business mailing address

524 GARDENDALE ST
FERNDALE MI
48220-2403
US

V. Phone/Fax

Practice location:
  • Phone: 415-548-0763
  • Fax:
Mailing address:
  • Phone: 415-548-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401226196
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: