Basic Information
| Provider Information | |||||||||
| NPI: | 1982093985 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR WELLSPRING AZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 E UNIVERSITY DR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852815617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803030844 | ||||||||
| FaxNumber: | 4803030848 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 E UNIVERSITY DR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852815617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803030844 | ||||||||
| FaxNumber: | 4803030848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2015 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOCKERY | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 5618681607 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERMEND HEALTH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 364SP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.