MEDICARE: WELLSPRING FAMILY COUNSELING, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	62399	TX

General Provider Information

NPI Number	:	1043468010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPRING FAMILY COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	1227 N VALLEY MILLS DR
Second Line	:	SUITE 206
City	:	WACO
State	:	TX
Zip	:	76710-4427
Country	:	US
Telephone Number	:	254-751-1164
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 N VALLEY MILLS DR
Second Line	:	SUITE 206
City	:	WACO
State	:	TX
Zip	:	76710-4427
Country	:	US
Telephone Number	:	254-751-1164
Fax Number	:

Authorized Official
Title or Position	:	LPC/OWNER
Name	:	JAMES DEREK SLOVER
Credential	:	M.A., LPC
Telephone Number	:	254-855-7699

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	09/03/2008

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