Provider Demographics
NPI:1447487533
Name:WELLSPRING THERAPY, PC
Entity type:Organization
Organization Name:WELLSPRING THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, MA
Authorized Official - Phone:773-793-4095
Mailing Address - Street 1:1112 N ASHLAND AVE
Mailing Address - Street 2:#1R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3935
Mailing Address - Country:US
Mailing Address - Phone:773-793-4095
Mailing Address - Fax:773-772-3528
Practice Address - Street 1:1112 N ASHLAND AVE
Practice Address - Street 2:#1R
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3935
Practice Address - Country:US
Practice Address - Phone:773-793-4095
Practice Address - Fax:773-772-3528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty