Provider Demographics
NPI:1144451121
Name:WELLSPRING COMMUNITY SUPPORT SERVICES, INC.
Entity type:Organization
Organization Name:WELLSPRING COMMUNITY SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:M
Authorized Official - Last Name:VON HENDY
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:570-662-1064
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-0574
Mailing Address - Country:US
Mailing Address - Phone:570-662-1064
Mailing Address - Fax:570-662-0966
Practice Address - Street 1:3RD & ST. JAMES STREET
Practice Address - Street 2:ST. JAMES COMPLEX #206B
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933
Practice Address - Country:US
Practice Address - Phone:570-662-2821
Practice Address - Fax:570-662-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-07
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA221170261Q00000X, 261QM0801X, 261QR0400X, 261QM0850X
PA222350261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation