Provider Demographics
NPI:1104515873
Name:RAQUEL WELLS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity type:Organization
Organization Name:RAQUEL WELLS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:415-535-8660
Mailing Address - Street 1:207 S. MCDOWELL BLVD, #1008
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-503-0569
Mailing Address - Fax:707-261-1258
Practice Address - Street 1:7285 BAKER LANE STUDIO
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:415-535-8660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAQUEL WELLS, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-08
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)