Basic Information
Provider Information | |||||||||
NPI: | 1386692911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLS | ||||||||
FirstName: | VICKI | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 PONDEROSA DR | ||||||||
Address2: | STE D | ||||||||
City: | CHRISTIANSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 24073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403821494 | ||||||||
FaxNumber: | 5403823039 | ||||||||
Practice Location | |||||||||
Address1: | 120 PONDEROSA DR | ||||||||
Address2: | STE D | ||||||||
City: | CHRISTIANSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 24073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403821494 | ||||||||
FaxNumber: | 5403823039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0701003566 | VA | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 142924 | 01 | VA | ANTHEM | OTHER | 521541 | 01 | VA | VALUE OPTIONS | OTHER |