Healthcare Provider Details

I. General information

NPI: 1528400454
Provider Name (Legal Business Name): WELLSPRING THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 WEST STREET SUITE 300
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

1804 WEST STREET SUITE 300
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 443-775-5177
  • Fax: 410-376-7611
Mailing address:
  • Phone: 443-775-5177
  • Fax: 410-376-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number03772
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number03772
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number03772
License Number StateMD

VIII. Authorized Official

Name: THEMBI DEPASS
Title or Position: CEO
Credential: MS/CCC-SLP
Phone: 240-495-1505