Healthcare Provider Details

I. General information

NPI: 1396786349
Provider Name (Legal Business Name): LOUISE ANNE WELLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MAIN ST STE 200
PLYMOUTH MI
48170-1250
US

IV. Provider business mailing address

340 N MAIN ST STE 200
PLYMOUTH MI
48170-1250
US

V. Phone/Fax

Practice location:
  • Phone: 734-335-0028
  • Fax: 734-335-3931
Mailing address:
  • Phone: 734-335-0028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016136-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016196
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: