Healthcare Provider Details

I. General information

NPI: 1659993509
Provider Name (Legal Business Name): WMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 S JUNIPER ST
PHILADELPHIA PA
19148-2217
US

IV. Provider business mailing address

6711 OLD YORK RD
PHILADELPHIA PA
19126-2841
US

V. Phone/Fax

Practice location:
  • Phone: 215-271-5822
  • Fax: 215-271-5881
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