NPIMap

Organization Active NPI

Wellspace Psychiatry LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Louisville, KY
National Provider Identifier
1710694468
Registry record updated Jul 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
WELLSPACE PSYCHIATRY LLC
Practice address
9700 Park Plaza Ave Unit 210
Louisville, KY 40241-2287
Phone
(502) 419-4289
NPI assigned
Nov 2, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2023

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

Authorized official

Name
Thomas J Federer
Title
Owner/Administrator
Phone
(502) 419-4289

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric/Mental Health Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP0808X Primary

Addresses

Primary practice location

9700 Park Plaza Ave Unit 210
Louisville, KY 40241-2287

Mailing address

9700 Park Plaza Ave Unit 210
Louisville, KY 40241-2287
Phone (502) 419-4289

Other identifiers 4

IdentifierTypeStateIssuer
1730733783OtherNPI 1
3013601OtherKYAPRN LICENSE
7100639170MedicaidKY
1128009OtherKYRN LICENSE

Other names 1

  • Wellspace Psychiatry Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20221230001592 KY Part B Supplier - Clinic/Group Practice 2163892423 Receives reassigned benefits from 1 practitioner
Practice locations: Louisville, KY

National Provider Directory

National Provider Directory

Locations

9700 Park Plaza Ave
Unit 210
Louisville, KY 40241
Phone (502) 419-4289

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1667347200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690243200000",
    "number": "1710694468",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9700 PARK PLAZA AVE UNIT 210",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402412287",
            "telephone_number": "502-419-4289"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9700 PARK PLAZA AVE UNIT 210",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402412287",
            "telephone_number": "502-419-4289"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSPACE PSYCHIATRY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-02",
        "last_updated": "2023-07-25",
        "certification_date": "2023-02-20",
        "status": "A",
        "authorized_official_last_name": "FEDERER",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER/ADMINISTRATOR",
        "authorized_official_telephone_number": "502-419-4289"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI 1",
            "identifier": "1730733783",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "APRN LICENSE",
            "identifier": "3013601",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100639170",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RN LICENSE",
            "identifier": "1128009",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wellspace Psychiatry",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Wellspace Psychiatry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Louisville, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2023; 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.