=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801319892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THANDI KENYETTA WELLS ED.S, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 SOUTHBRIDGE PKWY STE 650
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-919-3974
-----------------------------------------------------
Fax | 877-308-8259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100A SOUTHBRIDGE PKWY STE 235
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-919-3974
-----------------------------------------------------
Fax | 877-308-8259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 3472
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------