Provider Demographics
NPI:1083132310
Name:WELLSPRING PSYCHOTHERAPY CENTER
Entity Type:Organization
Organization Name:WELLSPRING PSYCHOTHERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-458-3358
Mailing Address - Street 1:30 N SAN PEDRO RD STE 290
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4133
Mailing Address - Country:US
Mailing Address - Phone:415-458-3358
Mailing Address - Fax:
Practice Address - Street 1:30 N SAN PEDRO RD STE 290
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4133
Practice Address - Country:US
Practice Address - Phone:415-458-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14624103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty