MEDICARE: CREST COUNSELING AND EDUCATIONAL SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	PC004392	PA

General Provider Information

NPI Number	:	1437456613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREST COUNSELING AND EDUCATIONAL SERVICES

Provider Business Mailing Address
First Line	:	7811 GERMANTOWN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3526
Country	:	US
Telephone Number	:	267-257-8978
Fax Number	:

Provider Business Practice Location Address
First Line	:	331 W MOUNT AIRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2941
Country	:	US
Telephone Number	:	267-257-8978
Fax Number	:	267-552-6283

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	DR. WILLIAM J. GILLESPIE
Credential	:	PSY.D.
Telephone Number	:	267-257-8978

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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