MEDICARE: WELLNESS SUPPORT COUNSELING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1003510975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS SUPPORT COUNSELING, LLC

Provider Business Mailing Address
First Line	:	6830 WAYNE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-3422
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 W WALNUT LN # 2D
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3204
Country	:	US
Telephone Number	:	215-399-6215
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	PATRICK GRUGAN
Credential	:	LCSW
Telephone Number	:	215-399-6215

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	12/06/2023

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