Provider Demographics
NPI:1255756565
Name:WELLSPRING PSYCHOLOGY GROUP LLC
Entity type:Organization
Organization Name:WELLSPRING PSYCHOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:812-797-7069
Mailing Address - Street 1:1340 CELEBRATION BLVD
Mailing Address - Street 2:UNIT A
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5585
Mailing Address - Country:US
Mailing Address - Phone:843-536-1180
Mailing Address - Fax:843-536-1116
Practice Address - Street 1:1340 CELEBRATION BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5585
Practice Address - Country:US
Practice Address - Phone:843-536-1180
Practice Address - Fax:843-536-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ346178236Medicare PIN