Basic Information
| Provider Information | |||||||||
| NPI: | 1790929214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 44899 CENTRE CT | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
| FaxNumber: | 5867921656 | ||||||||
| Practice Location | |||||||||
| Address1: | 44899 CENTRE CT | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
| FaxNumber: | 5867921656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4704186647 | MI | Y | Agencies | Community/Behavioral Health |
No ID Information.