MEDICARE: WELLSPRING MENTAL HEALTH GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1932669132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPRING MENTAL HEALTH GROUP

Provider Business Mailing Address
First Line	:	1982 SR 44
Second Line	:	SUITE 194
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168
Country	:	US
Telephone Number	:	386-316-7462
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 N DIXIE FWY
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-6069
Country	:	US
Telephone Number	:	386-410-3354
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	NATE INGRAM
Credential	:	MBA
Telephone Number	:	386-410-3354

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	03/22/2019

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