Healthcare Provider Details

I. General information

NPI: 1912262619
Provider Name (Legal Business Name): WELLSPRING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E PLEASANT ST
SPRINGFIELD OH
45506-2201
US

IV. Provider business mailing address

15 E PLEASANT ST
SPRINGFIELD OH
45506-2201
US

V. Phone/Fax

Practice location:
  • Phone: 937-325-5564
  • Fax: 937-325-8727
Mailing address:
  • Phone: 937-325-5564
  • Fax: 937-325-8727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: NAOMI WALTERS
Title or Position: OFFICE MANAGER/BILLER
Credential:
Phone: 937-325-5564