Provider Demographics
NPI:1003851411
Name:WELLSPRING
Entity Type:Organization
Organization Name:WELLSPRING
Other - Org Name:FAMILY SERVICE AGENCY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-325-5564
Mailing Address - Street 1:701 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-4404
Mailing Address - Country:US
Mailing Address - Phone:937-325-5564
Mailing Address - Fax:937-325-5564
Practice Address - Street 1:701 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4404
Practice Address - Country:US
Practice Address - Phone:937-325-5564
Practice Address - Fax:937-325-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0284101YA0400X, 101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10501Medicaid
OHFA9275051Medicare ID - Type UnspecifiedGROUP NUMBER