Healthcare Provider Details

I. General information

NPI: 1992818249
Provider Name (Legal Business Name): WELLSOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S EISENHOWER AVENUE
MASON CITY IA
50401
US

IV. Provider business mailing address

235 S EISENHOWER AVENUE
MASON CITY IA
50401
US

V. Phone/Fax

Practice location:
  • Phone: 641-424-2075
  • Fax: 641-424-9555
Mailing address:
  • Phone: 641-424-2075
  • Fax: 641-424-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW M EASTWOOD
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 641-424-2075