Provider Demographics
NPI:1710394911
Name:WELLSPRING PSYCHOLOGY PC
Entity Type:Organization
Organization Name:WELLSPRING PSYCHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-357-4102
Mailing Address - Street 1:409 ALBERTO WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-5407
Mailing Address - Country:US
Mailing Address - Phone:408-357-4102
Mailing Address - Fax:
Practice Address - Street 1:409 ALBERTO WAY STE 5
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-5407
Practice Address - Country:US
Practice Address - Phone:408-357-4102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-20
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty