Provider Demographics
NPI:1528400454
Name:WELLSPRING THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:WELLSPRING THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THEMBI
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPASS
Authorized Official - Suffix:
Authorized Official - Credentials:MS/CCC-SLP
Authorized Official - Phone:240-495-1505
Mailing Address - Street 1:1804 WEST STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:443-775-5177
Mailing Address - Fax:410-376-7611
Practice Address - Street 1:1804 WEST STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:443-775-5177
Practice Address - Fax:410-376-7611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03772225500000X, 252Y00000X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD453755993Medicaid
MD445005100Medicaid