Healthcare Provider Details

I. General information

NPI: 1063464055
Provider Name (Legal Business Name): WMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N BROAD ST
PHILADELPHIA PA
19126-2837
US

IV. Provider business mailing address

6711 OLD YORK RD
PHILADELPHIA PA
19126-2841
US

V. Phone/Fax

Practice location:
  • Phone: 215-276-3922
  • Fax: 215-924-4485
Mailing address:
  • Phone: 215-276-3922
  • Fax: 215-276-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TAKISA S GALLMAN
Title or Position: VP ADMINISTRATIVE SERVICES
Credential:
Phone: 215-276-3922