Healthcare Provider Details

I. General information

NPI: 1215442785
Provider Name (Legal Business Name): WELLSPRING FAMILY THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 W RIVERSIDE DR STE 203
BURBANK CA
91505-4050
US

IV. Provider business mailing address

4405 W RIVERSIDE DR STE 203
BURBANK CA
91505-4050
US

V. Phone/Fax

Practice location:
  • Phone: 818-238-9895
  • Fax: 818-238-9896
Mailing address:
  • Phone: 818-238-9895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUZETTE BRAY
Title or Position: CEO
Credential: LMFT
Phone: 818-856-1800