Provider Demographics
NPI:1154700110
Name:WELLSPRING OF LIFE, LLC
Entity type:Organization
Organization Name:WELLSPRING OF LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:814-812-9738
Mailing Address - Street 1:1163 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1869
Mailing Address - Country:US
Mailing Address - Phone:814-812-9738
Mailing Address - Fax:814-790-5999
Practice Address - Street 1:1163 E 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1869
Practice Address - Country:US
Practice Address - Phone:814-812-9738
Practice Address - Fax:814-790-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-23
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty