Healthcare Provider Details

I. General information

NPI: 1013838796
Provider Name (Legal Business Name): MATTHEW BLAINE WYMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 WALNUT ST STE 1350
PHILADELPHIA PA
19103-4775
US

IV. Provider business mailing address

1337 N 29TH ST
PHILADELPHIA PA
19121-4503
US

V. Phone/Fax

Practice location:
  • Phone: 610-892-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC020604
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: