Healthcare Provider Details

I. General information

NPI: 1811771124
Provider Name (Legal Business Name): AMELIA GRACE SALISBURY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MILES SALISBURY

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 BAINBRIDGE ST
PHILADELPHIA PA
19147-1810
US

IV. Provider business mailing address

2020 MORRIS ST
PHILADELPHIA PA
19145-2009
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-0652
  • Fax:
Mailing address:
  • Phone: 443-988-3216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW140497
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: