Provider Demographics
NPI:1306065230
Name:WELLBROOK, RICK W (LISAC)
Entity type:Individual
Prefix:MR
First Name:RICK
Middle Name:W
Last Name:WELLBROOK
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 W THATCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-3342
Mailing Address - Country:US
Mailing Address - Phone:928-428-8714
Mailing Address - Fax:928-428-8188
Practice Address - Street 1:1906 W THATCHER BLVD
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3342
Practice Address - Country:US
Practice Address - Phone:928-428-8714
Practice Address - Fax:928-428-8188
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0459101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)