Provider Demographics
NPI:1114024395
Name:WELLSPRING PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:WELLSPRING PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MERIANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:253-686-8033
Mailing Address - Street 1:33650 6TH AVE S
Mailing Address - Street 2:STE 100
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6754
Mailing Address - Country:US
Mailing Address - Phone:253-942-3308
Mailing Address - Fax:253-237-0643
Practice Address - Street 1:33650 6TH AVE S
Practice Address - Street 2:STE 100
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6754
Practice Address - Country:US
Practice Address - Phone:253-942-3308
Practice Address - Fax:253-237-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007405261QP2000X
WAPT00009213261QP2000X
WAPT00009987261QP2000X
WAPT00003078261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy