Provider Demographics
NPI:1326336199
Name:WELLSPRING PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:WELLSPRING PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRANFORD BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:860-677-2244
Mailing Address - Street 1:152 SIMSBURY RD # 9B
Mailing Address - Street 2:BUILDING 9
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3777
Mailing Address - Country:US
Mailing Address - Phone:860-677-2244
Mailing Address - Fax:
Practice Address - Street 1:152 SIMSBURY RD # 9B
Practice Address - Street 2:BUILDING 9
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3777
Practice Address - Country:US
Practice Address - Phone:860-677-2244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003031251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health