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General NPI Number Information
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NPI Number | 1417726282
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Entity Type | Organization
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Legal Business Name | WELLSPRING MENTAL HEALTH LLC
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Dates
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Enumeration Date | 12/21/2023
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Last Update Date | 12/21/2023
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Provider Practice Location Address
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Address Line | 204 W MAIN ST UNIT E
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City | HORTONVILLE
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State | WI
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Zip | 54944-8556
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Country | US
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Telephone | 920-393-8355
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Fax | 920-580-0150
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Provider Business Mailing Address
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Address Line | PO BOX 165
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City | HORTONVILLE
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State | WI
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Zip | 54944-0165
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Country | US
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Telephone | 920-393-8355
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Fax | 920-580-0150
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Authorized Official
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Title or Position | OWNER
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Name | GRETCHEN DOMINOWSKI
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Credential | LPC
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Telephone | 920-393-8355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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