NPIMap

Organization Active NPI

Wellspring of Life, LLC

  • Professional Counselor
  • Erie, PA
National Provider Identifier
1154700110
Registry record updated Dec 20, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Professional CounselorTaxonomy code 101YP2500X
Legal business name
WELLSPRING OF LIFE, LLC
Practice address
1163 E 38TH St
Erie, PA 16504-1869
Phone
(814) 812-9738
Fax
(814) 790-5999
NPI assigned
May 23, 2015
Last updated
Dec 20, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 20, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Patrick Damond, LPC, NCCNPI 1053445312
Title
Owner
Phone
(814) 812-9738

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Professional Counselor 101YP2500X Primary

Addresses

Primary practice location

1163 E 38TH St
Erie, PA 16504-1869

Mailing address

1163 E 38TH St
Erie, PA 16504-1869
Phone (814) 812-9738

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241113002333 PA Part B Supplier - Clinic/Group Practice 1456885425 Receives reassigned benefits from 2 practitioners
Practice locations: Erie, PA

National Provider Directory

National Provider Directory

Locations

1163 E 38th St
Erie, PA 16504
Phone (814) 812-9738

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576800000000",
    "number": "1154700110",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1163 E 38TH ST",
            "city": "ERIE",
            "state": "PA",
            "postal_code": "165041869",
            "telephone_number": "814-812-9738",
            "fax_number": "814-790-5999"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1163 E 38TH ST",
            "city": "ERIE",
            "state": "PA",
            "postal_code": "165041869",
            "telephone_number": "814-812-9738",
            "fax_number": "814-790-5999"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSPRING OF LIFE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-23",
        "last_updated": "2019-12-20",
        "certification_date": "2019-12-20",
        "status": "A",
        "authorized_official_last_name": "DAMOND",
        "authorized_official_first_name": "PATRICK",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "814-812-9738",
        "authorized_official_credential": "LPC, NCC"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Erie, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.