Healthcare Provider Details

I. General information

NPI: 1710694468
Provider Name (Legal Business Name): WELLSPACE PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 07/25/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 PARK PLAZA AVE UNIT 210
LOUISVILLE KY
40241-2287
US

IV. Provider business mailing address

9700 PARK PLAZA AVE UNIT 210
LOUISVILLE KY
40241-2287
US

V. Phone/Fax

Practice location:
  • Phone: 502-419-4289
  • Fax:
Mailing address:
  • Phone: 502-419-4289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: THOMAS J FEDERER
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 502-419-4289