Provider Demographics
NPI:1730346339
Name:WELLSPRING FARM LLC
Entity type:Organization
Organization Name:WELLSPRING FARM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:VOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MA CAGS LCSW
Authorized Official - Phone:508-763-5896
Mailing Address - Street 1:42 HILLER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02770
Mailing Address - Country:US
Mailing Address - Phone:508-763-5896
Mailing Address - Fax:508-763-5896
Practice Address - Street 1:42 HILLER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02770
Practice Address - Country:US
Practice Address - Phone:508-763-5896
Practice Address - Fax:508-763-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1041C0700X, 163W00000X, 208000000X, 225100000X, 225X00000X, 235Z00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWWELL001AOtherMA DMR AUTISM WAIVER NUMBER
MA0038463OtherCOMMUNITY MEDICAL ALLIANCE
MA1016266Medicaid
MAVCG000188774ADOtherMA STATE VENDOR