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General NPI Number Information
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NPI Number | 1083132310
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Entity Type | Organization
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Legal Business Name | WELLSPRING PSYCHOTHERAPY CENTER
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Dates
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Enumeration Date | 09/07/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 30 N SAN PEDRO RD STE 290
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City | SAN RAFAEL
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State | CA
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Zip | 94903-4133
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Country | US
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Telephone | 415-458-3358
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Fax |
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Provider Business Mailing Address
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Address Line | 30 N SAN PEDRO RD STE 290
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City | SAN RAFAEL
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State | CA
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Zip | 94903-4133
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Country | US
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Telephone | 415-458-3358
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. SIMONE RODIN
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Credential | PH.D.
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Telephone | 415-458-3358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY14624
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License Number State | CA
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