=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114604154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA CRECELIUS WELLS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2023
-----------------------------------------------------
Last Update Date | 06/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 BEAR MOUNTAIN TRL
-----------------------------------------------------
City | HELEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-270-1893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2259
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-0040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-270-1893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW008236
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------