Healthcare Provider Details

I. General information

NPI: 1700532025
Provider Name (Legal Business Name): ANNA VRESILOVIC MSED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST STE 2100
PHILADELPHIA PA
19103-6211
US

IV. Provider business mailing address

3207 BARING ST FL 1
PHILADELPHIA PA
19104-2510
US

V. Phone/Fax

Practice location:
  • Phone: 215-514-6954
  • Fax:
Mailing address:
  • Phone: 610-529-6584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC012629
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: