Healthcare Provider Details

I. General information

NPI: 1467201277
Provider Name (Legal Business Name): HEATHER ANN BALLOU WELLS M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 NW EASTMAN PKWY
GRESHAM OR
97030-3896
US

IV. Provider business mailing address

39995 MITCHELL CT
SANDY OR
97055-9318
US

V. Phone/Fax

Practice location:
  • Phone: 503-264-4653
  • Fax: 503-261-4669
Mailing address:
  • Phone: 503-914-7761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number011965
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: