Provider Demographics
NPI:1689481723
Name:WELLS, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MANZANITA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3009
Mailing Address - Country:US
Mailing Address - Phone:415-686-3732
Mailing Address - Fax:
Practice Address - Street 1:6041 BRISTOL PKWY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90230-6601
Practice Address - Country:US
Practice Address - Phone:415-686-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker