Basic Information
Provider Information | |||||||||
NPI: | 1619188794 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSPRING COUNSELING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSPRING COUNSELING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1335 DUBLIN ROAD | ||||||||
Address2: | SUITE 100A | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 43215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145380353 | ||||||||
FaxNumber: | 6144293219 | ||||||||
Practice Location | |||||||||
Address1: | 1335 DUBLIN ROAD | ||||||||
Address2: | SUITE 100A | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 43215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145380353 | ||||||||
FaxNumber: | 6144293219 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 04/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORENO | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6145380353 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPCC-S | ||||||||
NPICertificationDate: | 04/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.