Provider Demographics
NPI:1396215018
Name:WELLSPRING COUNSELING SOUTH CAROLINA
Entity Type:Organization
Organization Name:WELLSPRING COUNSELING SOUTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:803-743-5098
Mailing Address - Street 1:813 LEYLAND CYPRESS CT
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7647
Mailing Address - Country:US
Mailing Address - Phone:803-743-5098
Mailing Address - Fax:866-718-3107
Practice Address - Street 1:6156 SAINT ANDREWS RD STE 105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3147
Practice Address - Country:US
Practice Address - Phone:803-743-5098
Practice Address - Fax:866-718-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty