Basic Information
| Provider Information | |||||||||
| NPI: | 1336538578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSPRING REHABILITATION SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1124 SE 1ST ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477131322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127600709 | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 W MAIN ST APT E | ||||||||
| Address2: | |||||||||
| City: | ISLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423502179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127607090 | ||||||||
| FaxNumber: | 8122052425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2015 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8127600709 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSCCCSLP | ||||||||
| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7100593640 | 05 | KY | MEDICAID |