Organization
WELLSPACE PSYCHIATRY LLC
Active
Other names
Wellspace Psychiatry
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS J FEDERER (OWNER/ADMINISTRATOR)
(502) 419-4289
Entity
Organization
Contact information
Practice address
9700 PARK PLAZA AVE UNIT 210, LOUISVILLE, KY 40241-2287
(502) 419-4289
Mailing address
9700 PARK PLAZA AVE UNIT 210, LOUISVILLE, KY 40241-2287
(502) 419-4289
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1128009
RN LICENSE
KY
01
—
1730733783
NPI 1
—
01
—
3013601
APRN LICENSE
KY
05
—
7100639170
—
KY
Enumeration date
11/02/2022
Last updated
07/25/2023
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