MEDICARE: COPPERSPRING WELLNESS LLC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1720761521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPPERSPRING WELLNESS LLC

Provider Business Mailing Address
First Line	:	6670 CHALK HILL LN
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94591-3866
Country	:	US
Telephone Number	:	510-456-0475
Fax Number	:

Provider Business Practice Location Address
First Line	:	6670 CHALK HILL LN
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94591-3866
Country	:	US
Telephone Number	:	510-456-0475
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	YUN JIN CARSON
Credential	:	LCSW
Telephone Number	:	510-456-0475

Provider Enumeration Date	:	08/08/2023
Last Update Date	:	08/08/2023

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