Provider Demographics
NPI:1487164406
Name:WELLS, ERIK VERNON (CSW)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:VERNON
Last Name:WELLS
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 OLD HWY 91
Mailing Address - Street 2:
Mailing Address - City:MONA
Mailing Address - State:UT
Mailing Address - Zip Code:84645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 OLD HWY 91
Practice Address - Street 2:
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84645
Practice Address - Country:US
Practice Address - Phone:435-623-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9753116-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty