Healthcare Provider Details

I. General information

NPI: 1972301141
Provider Name (Legal Business Name): WELLSPRING MENTAL HEALTH PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MAIN ST
CLAYTON NM
88415-3041
US

IV. Provider business mailing address

PO BOX 572
CLAYTON NM
88415-0572
US

V. Phone/Fax

Practice location:
  • Phone: 575-374-2993
  • Fax:
Mailing address:
  • Phone: 575-447-2993
  • 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: HANNAH WELLS
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 575-447-2993