Provider Demographics
NPI:1568694511
Name:WELLSPRING, INC.
Entity Type:Organization
Organization Name:WELLSPRING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR REGISTERED AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, CCS
Authorized Official - Phone:207-941-1612
Mailing Address - Street 1:98 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253-255 HAMMOND ST.
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-941-1612
Practice Address - Fax:207-941-1634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSPRING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME571380251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME164940100Medicaid