Basic Information
| Provider Information | |||||||||
| NPI: | 1750551867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPRING PSYCHOLOGICAL ASSOCIATES, P.L.L.C.WELLSPRING PSYCHO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12012 WICKCHESTER LN | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770791229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482830 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Practice Location | |||||||||
| Address1: | 658 SW 3RD ST | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750511805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482830 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FEE | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8324482800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0033QU | 01 | TX | BCBS | OTHER | DG5459 | 01 | TX | RAILROAD MEDICARE | OTHER |