Healthcare Provider Details

I. General information

NPI: 1821215203
Provider Name (Legal Business Name): WMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 S JUNIPER ST
PHILADELPHIA PA
19148-2217
US

IV. Provider business mailing address

1939 S JUNIPER ST
PHILADELPHIA PA
19148-2217
US

V. Phone/Fax

Practice location:
  • Phone: 215-271-5822
  • Fax: 215-271-5881
Mailing address:
  • Phone: 215-271-5822
  • Fax: 215-271-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number192780
License Number StatePA

VIII. Authorized Official

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