Basic Information
| Provider Information | |||||||||
| NPI: | 1700392529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSPACE HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WELLSPACE HEALTH STRATEGIES FOR CHANGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 12TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958141929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164694690 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958173301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162776600 | ||||||||
| FaxNumber: | 9163953683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2017 | ||||||||
| LastUpdateDate: | 12/15/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTEUS | ||||||||
| AuthorizedOfficialFirstName: | ALASDAIR | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9165505444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.