Provider Demographics
NPI:1992215917
Name:WELLSPRING COUNSELING SERVICES
Entity type:Organization
Organization Name:WELLSPRING COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCMH
Authorized Official - Phone:302-373-8904
Mailing Address - Street 1:623 E RADISON RUN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:DE
Mailing Address - Zip Code:19938-3837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 E GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1424
Practice Address - Country:US
Practice Address - Phone:302-373-8904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE0000536101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1588928816Medicaid