Provider Demographics
NPI:1417726282
Name:WELLSPRING MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:WELLSPRING MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-393-8355
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-0165
Mailing Address - Country:US
Mailing Address - Phone:920-393-8355
Mailing Address - Fax:920-580-0150
Practice Address - Street 1:204 W MAIN ST UNIT E
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944-8556
Practice Address - Country:US
Practice Address - Phone:920-393-8355
Practice Address - Fax:920-580-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty