MEDICARE: WELLSPRING THERAPEUTIC PARTNERS, 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	101Y00000X	Counselor	6401011566	MI

General Provider Information

NPI Number	:	1801293592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPRING THERAPEUTIC PARTNERS, LLC

Provider Business Mailing Address
First Line	:	42815 GARFIELD RD
Second Line	:	SUITE 210
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1143
Country	:	US
Telephone Number	:	586-212-8218
Fax Number	:	586-408-6485

Provider Business Practice Location Address
First Line	:	42815 GARFIELD RD
Second Line	:	SUITE 210
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-1143
Country	:	US
Telephone Number	:	586-212-8218
Fax Number	:	586-408-6485

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	JESSICA R COUCH
Credential	:	MA
Telephone Number	:	586-212-8218

Provider Enumeration Date	:	11/25/2014
Last Update Date	:	02/04/2016

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