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General NPI Number Information
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NPI Number | 1518661305
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Entity Type | Organization
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Legal Business Name | WELLSPRING LIFE CENTER, LLC
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Dates
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Enumeration Date | 03/28/2023
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Last Update Date | 03/28/2023
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Provider Practice Location Address
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Address Line | 20150 LAKE SHORE BLVD
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City | EUCLID
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State | OH
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Zip | 44123-1839
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Country | US
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Telephone | 216-714-2151
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Fax |
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Provider Business Mailing Address
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Address Line | 20150 LAKE SHORE BLVD
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City | EUCLID
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State | OH
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Zip | 44123-1839
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Country | US
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Telephone | 216-714-2151
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. TAMIKA MOORE
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Credential | LISW-S
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Telephone | 216-714-2151
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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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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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