Provider Demographics
NPI:1790774115
Name:WELLSPRING COUNSELING LLC
Entity Type:Organization
Organization Name:WELLSPRING COUNSELING LLC
Other - Org Name:BRYCE M. MITCHELL DBA WELLSPRING PSYCHOTHERAPY & COUNSELING CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RYEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:608-274-5871
Mailing Address - Street 1:5610 MEDICAL CIRCLE #25
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1295
Mailing Address - Country:US
Mailing Address - Phone:608-274-5871
Mailing Address - Fax:608-274-5764
Practice Address - Street 1:5610 MEDICAL CIRCLE #25
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1295
Practice Address - Country:US
Practice Address - Phone:608-274-5871
Practice Address - Fax:608-274-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1983261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42198500Medicaid
WI42198500Medicaid