Provider Demographics
NPI:1124304340
Name:WELLS, MAROLYN CLARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MAROLYN
Middle Name:CLARK
Last Name:WELLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 MARLBROOK DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1768
Mailing Address - Country:US
Mailing Address - Phone:404-783-0081
Mailing Address - Fax:
Practice Address - Street 1:1827 MARLBROOK DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1768
Practice Address - Country:US
Practice Address - Phone:404-783-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001073103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist