Provider Demographics
NPI:1053833939
Name:WELLSPRING RENEWAL CENTER
Entity Type:Organization
Organization Name:WELLSPRING RENEWAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPOONER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:501-265-0046
Mailing Address - Street 1:101 N WOODROW ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4341
Mailing Address - Country:US
Mailing Address - Phone:1501-265-0046
Mailing Address - Fax:
Practice Address - Street 1:101 N WOODROW ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4341
Practice Address - Country:US
Practice Address - Phone:1501-265-0046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1101005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty