Healthcare Provider Details

I. General information

NPI: 1154475184
Provider Name (Legal Business Name): THE WELLSPRING FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ARCH BRIDGE RD.
BETHLEHEM CT
06751-0370
US

IV. Provider business mailing address

21 ARCH BRIDGE RD. P.O. BOX 370
BETHLEHEM CT
06751-0370
US

V. Phone/Fax

Practice location:
  • Phone: 203-266-8000
  • Fax: 203-266-8030
Mailing address:
  • Phone: 203-266-8000
  • Fax: 203-266-8030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberCCF RT 26
License Number StateCT

VIII. Authorized Official

Name: MR. HARVEY NEWMAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.ED
Phone: 203-266-8110