Healthcare Provider Details

I. General information

NPI: 1124642293
Provider Name (Legal Business Name): WELLSPRING BEHAVIORAL HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 E IRON EAGLE DR STE 100
EAGLE ID
83616-6868
US

IV. Provider business mailing address

1159 E IRON EAGLE DR STE 100
EAGLE ID
83616-6868
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-2836
  • Fax: 208-938-2897
Mailing address:
  • Phone: 208-938-2836
  • Fax: 208-938-2897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ASHLEY CROFT
Title or Position: OWNER/PROVIDER
Credential: DNP, PMHNP
Phone: 208-938-2836