Basic Information
| Provider Information | |||||||||
| NPI: | 1700010212 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPRING OF LIFE COUNSELING & PLAY THERAPY CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5505 GRISSOM RD STE 128 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782383038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106804747 | ||||||||
| FaxNumber: | 2106804775 | ||||||||
| Practice Location | |||||||||
| Address1: | 5505 GRISSOM RD STE 128 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782383038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106804747 | ||||||||
| FaxNumber: | 2106804775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VILLARREAL | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LPC, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2106804747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.