Healthcare Provider Details

I. General information

NPI: 1053456681
Provider Name (Legal Business Name): AMY ELLEN GEDRICH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WOODLAND AVE VA MEDICAL CENTER
PHILADELPHIA PA
19104-4551
US

IV. Provider business mailing address

622 S BAMBREY ST
PHILADELPHIA PA
19146-1021
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-4300
  • Fax:
Mailing address:
  • Phone: 267-251-6310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW015320
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: