Provider Demographics
NPI:1114371697
Name:WELLSPRINGS HOLISTIC MEDICINE LLC
Entity Type:Organization
Organization Name:WELLSPRINGS HOLISTIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DELAURENTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:609-481-5830
Mailing Address - Street 1:813 E GATE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1238
Mailing Address - Country:US
Mailing Address - Phone:609-481-5830
Mailing Address - Fax:856-222-9916
Practice Address - Street 1:813 E GATE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1238
Practice Address - Country:US
Practice Address - Phone:609-481-5830
Practice Address - Fax:856-222-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI00144600103T00000X
NJ25MB05189200208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty