Healthcare Provider Details

I. General information

NPI: 1114144508
Provider Name (Legal Business Name): WMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4913 N BROAD ST
PHILADELPHIA PA
19141-2215
US

IV. Provider business mailing address

4913 N BROAD ST
PHILADELPHIA PA
19141-2215
US

V. Phone/Fax

Practice location:
  • Phone: 215-329-3200
  • Fax: 215-329-3217
Mailing address:
  • Phone: 215-329-3200
  • Fax: 215-329-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number192780
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number192780
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number192780
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number192780
License Number StatePA

VIII. Authorized Official

Name: MRS. TAKISA S GALLMAN
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 215-276-3922