Provider Demographics
NPI:1316700172
Name:WELLS, OLIVIA MICHELE (PTA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MICHELE
Last Name:WELLS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4428
Mailing Address - Country:US
Mailing Address - Phone:914-631-9020
Mailing Address - Fax:914-631-9028
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-3450
Practice Address - Country:US
Practice Address - Phone:732-493-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00397700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant