Healthcare Provider Details

I. General information

NPI: 1922112077
Provider Name (Legal Business Name): WELL-SPRING PSYCHIATRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 WAYNE ST
TRAVERSE CITY MI
49684-1432
US

IV. Provider business mailing address

PO BOX 107
LAKE ANN MI
49650-0107
US

V. Phone/Fax

Practice location:
  • Phone: 231-922-9625
  • Fax: 231-929-5594
Mailing address:
  • Phone: 231-922-9625
  • Fax: 231-929-5594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARILYN EILEEN CONLON
Title or Position: PRESIDENT
Credential: M.D.,
Phone: 231-922-9625