Healthcare Provider Details

I. General information

NPI: 1114483096
Provider Name (Legal Business Name): WELLSPRING MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 PHOENIX AVE NE
ALBUQUERQUE NM
87110-3144
US

IV. Provider business mailing address

5400 PHOENIX AVE NE
ALBUQUERQUE NM
87110-3144
US

V. Phone/Fax

Practice location:
  • Phone: 505-331-7815
  • Fax:
Mailing address:
  • Phone: 505-331-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY CAMILLE CUNNINGHAM
Title or Position: SOLE MBR
Credential:
Phone: 505-331-7815