Healthcare Provider Details

I. General information

NPI: 1053137240
Provider Name (Legal Business Name): WELLSPRING GRIEF JOURNEY SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 FOX HOLLOW PL NW
ALBUQUERQUE NM
87114-1833
US

IV. Provider business mailing address

1011 FOX HOLLOW PL NW
ALBUQUERQUE NM
87114-1833
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-5232
  • Fax:
Mailing address:
  • Phone: 505-239-5232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KRISTIN D MONTES
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 505-239-5232