Provider Demographics
NPI:1548696602
Name:WELLS, DAVID MATTHEW
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MATTHEW
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 36TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2304
Mailing Address - Country:US
Mailing Address - Phone:763-509-3800
Mailing Address - Fax:
Practice Address - Street 1:11505 36TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2304
Practice Address - Country:US
Practice Address - Phone:763-509-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MNLP5931103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program