Provider Demographics
NPI:1891223541
Name:WELLS, THOMAS ANTHONY (LCSW, MASTERS CASAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:WELLS
Suffix:
Gender:M
Credentials:LCSW, MASTERS CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 BROADWAY STE 4921
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207-2922
Mailing Address - Country:US
Mailing Address - Phone:518-394-0182
Mailing Address - Fax:518-836-0648
Practice Address - Street 1:418 BROADWAY STE 4921
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-2922
Practice Address - Country:US
Practice Address - Phone:518-394-0182
Practice Address - Fax:518-836-0648
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31568101YA0400X
NY105434104100000X
CT0142481041C0700X
DCLC2000035261041C0700X
NY0935041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid