Provider Demographics
NPI:1891823332
Name:WELLSPRING INC.
Entity Type:Organization
Organization Name:WELLSPRING INC.
Other - Org Name:SOARING EAGLE TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:CCDCIII, CCSII,
Authorized Official - Phone:605-718-4870
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-1087
Mailing Address - Country:US
Mailing Address - Phone:605-718-4870
Mailing Address - Fax:605-718-4878
Practice Address - Street 1:117 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0693
Practice Address - Country:US
Practice Address - Phone:605-718-4870
Practice Address - Fax:605-718-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YA0400X, 324500000X
SD18872084P0800X
SDR72 97406322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5160320Medicaid
SD5005080Medicaid
SD5005082Medicaid
SD7100744Medicaid