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NPI Code Detail

MEDICARE: WELLSTONE, INC.

MEDICARE: WELLSTONE, INC.
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
1101YA0400XAddiction (Substance Use Disorder) Counselor
2103TC0700XClinical Psychologist
31041C0700XClinical Social Worker
4106H00000XMarriage & Family Therapist
52084P0800XPsychiatry Physician
62084P0804XChild & Adolescent Psychiatry Physician
72084P0805XGeriatric Psychiatry Physician
8101YM0800XMental Health Counselor

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1407809213
Entity Type Code : Organization
Provider Name (Legal Business Name) : WELLSTONE, INC.
Provider Business Mailing Address
First Line : 4040 MEMORIAL PKWY SW
Second Line :
City : HUNTSVILLE
State : AL
Zip : 35802-4364
Country : US
Telephone Number : 256-533-1970
Fax Number : 256-532-4141
Provider Business Practice Location Address
First Line : 4040 MEMORIAL PKWY SW
Second Line :
City : HUNTSVILLE
State : AL
Zip : 35802-4364
Country : US
Telephone Number : 256-533-1970
Fax Number : 256-532-4141
Authorized Official
Title or Position : HUMAN RESOURCES MANAGER
Name : MRS. TORI L LOVELL
Credential : BS
Telephone Number : 256-705-6312
Provider Enumeration Date : 05/19/2006
Last Update Date : 06/23/2020

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1063455194 — DR. RANDAL K BURLESON PSY.D.
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Directions to “WELLSTONE, INC. ” Practice Location

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