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General NPI Number Information
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NPI Number | 1861002461
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Entity Type | Organization
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Legal Business Name | MATERNAL WELLNESS CENTER LLC
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Dates
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Enumeration Date | 08/07/2020
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Last Update Date | 08/07/2020
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Provider Practice Location Address
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Address Line | 67 BYBERRY RD
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City | HATBORO
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State | PA
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Zip | 19040-3205
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Country | US
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Telephone | 215-649-9916
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Fax |
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Provider Business Mailing Address
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Address Line | 88 W WASHINGTON LN
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City | PHILADELPHIA
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State | PA
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Zip | 19144-2602
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Country | US
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Telephone | 267-432-2374
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Fax |
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Authorized Official
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Title or Position | OWNER / DIRECTOR
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Name | MS. KELLIE L. WICKLUND
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Credential | MA, LPC, PHM-C
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Telephone | 267-432-2374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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