Healthcare Provider Details

I. General information

NPI: 1124806344
Provider Name (Legal Business Name): WELLS OF LIFE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 01/23/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10536 AUTO MALL PKWY STE B
DIBERVILLE MS
39540-3742
US

IV. Provider business mailing address

PO BOX 267
PEARL RIVER LA
70452-0267
US

V. Phone/Fax

Practice location:
  • Phone: 985-260-1914
  • Fax:
Mailing address:
  • Phone: 504-329-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN P. PETRIE
Title or Position: CEO
Credential: LPC
Phone: 985-260-1914