Healthcare Provider Details

I. General information

NPI: 1003372368
Provider Name (Legal Business Name): CHELSEA KAE WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6692 SPRING ARBOR RD
JACKSON MI
49201-9322
US

IV. Provider business mailing address

577 NORVELL BEACH DR
BROOKLYN MI
49230-9528
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-3869
  • Fax:
Mailing address:
  • Phone: 734-776-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301016657
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: