Provider Demographics
NPI:1427725811
Name:WELLS JR, GREGORY (LCADC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WELLS JR
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 N MAPLE AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3232
Mailing Address - Country:US
Mailing Address - Phone:201-956-9483
Mailing Address - Fax:201-288-5262
Practice Address - Street 1:61 N MAPLE AVE STE 302
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3232
Practice Address - Country:US
Practice Address - Phone:201-956-9483
Practice Address - Fax:201-288-5262
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00120200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37LC00120200OtherSTATE LICENSE