Provider Demographics
NPI:1275526303
Name:WELLSPRING, INC.
Entity Type:Organization
Organization Name:WELLSPRING, INC.
Other - Org Name:WELLSPRING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR REGISTERED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, CCS
Authorized Official - Phone:207-941-1612
Mailing Address - Street 1:98 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5234
Mailing Address - Country:US
Mailing Address - Phone:207-941-1612
Mailing Address - Fax:207-941-1634
Practice Address - Street 1:255 HAMMOND ST.
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5294
Practice Address - Country:US
Practice Address - Phone:207-941-1612
Practice Address - Fax:207-941-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME291041251S00000X
ME290961324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME164940003Medicaid
ME164940000Medicaid
ME164940002Medicaid
ME164940100Medicaid
ME164940001Medicaid
ME164940002Medicaid