Provider Demographics
NPI:1912262619
Name:WELLSPRING
Entity Type:Organization
Organization Name:WELLSPRING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/BILLER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-325-5564
Mailing Address - Street 1:15 E PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-2201
Mailing Address - Country:US
Mailing Address - Phone:937-325-5564
Mailing Address - Fax:937-325-8727
Practice Address - Street 1:15 E PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-2201
Practice Address - Country:US
Practice Address - Phone:937-325-5564
Practice Address - Fax:937-325-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH286442Medicaid
OH286442Medicaid