Healthcare Provider Details

I. General information

NPI: 1245948272
Provider Name (Legal Business Name): MELANIN MOMMY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 WOODLAND AVE APT 305
DREXEL HILL PA
19026-3929
US

IV. Provider business mailing address

4211 WOODLAND AVE APT 305
DREXEL HILL PA
19026-3929
US

V. Phone/Fax

Practice location:
  • Phone: 717-491-3666
  • Fax: 267-433-3994
Mailing address:
  • Phone: 717-491-3666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KARINA BAILEY
Title or Position: OWNER/CEO
Credential: LPC
Phone: 610-675-3733