MEDICARE: RESILIENCE, GRIT AND MINDSET LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1619747128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESILIENCE, GRIT AND MINDSET LLC

Provider Business Mailing Address
First Line	:	5115 W DAKOTA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-2414
Country	:	US
Telephone Number	:	215-908-3613
Fax Number	:

Provider Business Practice Location Address
First Line	:	5115 W DAKOTA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-2414
Country	:	US
Telephone Number	:	215-908-3613
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPT
Name	:	MR. JOSEPH GARY WILLIAMS
Credential	:	LCSW
Telephone Number	:	215-908-3613

Provider Enumeration Date	:	01/05/2024
Last Update Date	:	01/05/2024

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