Provider Demographics
NPI:1154475184
Name:THE WELLSPRING FOUNDATION, INC.
Entity Type:Organization
Organization Name:THE WELLSPRING FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:203-266-8110
Mailing Address - Street 1:21 ARCH BRIDGE RD.
Mailing Address - Street 2:P.O. BOX 370
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-0370
Mailing Address - Country:US
Mailing Address - Phone:203-266-8000
Mailing Address - Fax:203-266-8030
Practice Address - Street 1:21 ARCH BRIDGE RD.
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:CT
Practice Address - Zip Code:06751-0370
Practice Address - Country:US
Practice Address - Phone:203-266-8000
Practice Address - Fax:203-266-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0850X, 261QM0855X
CTCCF RT 26323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040929Medicaid
CT004040929Medicaid