MEDICARE: WEST PHILA COMMUNITY MENTAL HEALTH CONSORTIUM, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	PA
2	101YM0800X	Mental Health Counselor	PA
3	101YM0800X	Mental Health Counselor
4	2084P0800X	Psychiatry Physician
5	251B00000X	Case Management Agency
6	251S00000X	Community/Behavioral Health Agency
7	261QM0850X	Adult Mental Health Clinic/Center
8	261QM0855X	Adolescent and Children Mental Health Clinic/Center
9	101Y00000X	Counselor	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194757989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PHILA COMMUNITY MENTAL HEALTH CONSORTIUM, INC.

Provider Business Mailing Address
First Line	:	3751 ISLAND AVE STE 303
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19153-3237
Country	:	US
Telephone Number	:	215-596-8100
Fax Number	:	215-382-0511

Provider Business Practice Location Address
First Line	:	137 S 58TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139
Country	:	US
Telephone Number	:	215-596-8100
Fax Number	:	215-382-0511

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. JOHN F WHITE JR.
Credential	:	N/A
Telephone Number	:	215-596-8100

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/02/2024

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