Healthcare Provider Details

I. General information

NPI: 1386034049
Provider Name (Legal Business Name): WELLSPRING WELLNESS AND MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S KANNER HWY SUITE 2
STUART FL
34994-4600
US

IV. Provider business mailing address

2500 S KANNER HWY SUITE 2
STUART FL
34994-4600
US

V. Phone/Fax

Practice location:
  • Phone: 772-320-1555
  • Fax: 772-320-1557
Mailing address:
  • Phone: 772-320-1555
  • Fax: 772-320-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1943AD531301
License Number StateOH

VIII. Authorized Official

Name: MS. JOAN COLLINS
Title or Position: QWNER/EXECUTIVE DIRECTOR
Credential:
Phone: 772-320-1555