Provider Demographics
NPI:1477962421
Name:WELLSPRING CHILD AND FAMILY PSYCHOLOGY, PC
Entity Type:Organization
Organization Name:WELLSPRING CHILD AND FAMILY PSYCHOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:540-478-3253
Mailing Address - Street 1:615 EMANCIPATION HWY
Mailing Address - Street 2:STE 101
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8407
Mailing Address - Country:US
Mailing Address - Phone:540-693-0096
Mailing Address - Fax:
Practice Address - Street 1:615 EMANCIPATION HWY
Practice Address - Street 2:STE 101
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8407
Practice Address - Country:US
Practice Address - Phone:540-693-0096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004284103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF204Medicare PIN