Healthcare Provider Details

I. General information

NPI: 1982093985
Provider Name (Legal Business Name): DR WELLSPRING AZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 E UNIVERSITY DR SUITE 301
TEMPE AZ
85281-5617
US

IV. Provider business mailing address

20 E UNIVERSITY DR SUITE 301
TEMPE AZ
85281-5617
US

V. Phone/Fax

Practice location:
  • Phone: 480-303-0844
  • Fax: 480-303-0848
Mailing address:
  • Phone: 480-303-0844
  • Fax: 480-303-0848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEAN ANN DOCKERY
Title or Position: DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 561-868-1607