Healthcare Provider Details

I. General information

NPI: 1144873126
Provider Name (Legal Business Name): WMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4243 FRANKFORD AVE
PHILADELPHIA PA
19124-4520
US

IV. Provider business mailing address

6711 OLD YORK RD OFC
PHILADELPHIA PA
19126-2841
US

V. Phone/Fax

Practice location:
  • Phone: 215-276-3922
  • Fax: 215-744-1400
Mailing address:
  • Phone: 215-276-3922
  • Fax: 215-276-1249

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