MEDICARE: DD THERAPY SOURCES 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1639812415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DD THERAPY SOURCES LLC

Provider Business Mailing Address
First Line	:	87 OLD CEDARBROOK RD
Second Line	:
City	:	WYNCOTE
State	:	PA
Zip	:	19095-2045
Country	:	US
Telephone Number	:	215-341-1020
Fax Number	:	267-627-2848

Provider Business Practice Location Address
First Line	:	2630 W CHELTENHAM AVE FL 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-1311
Country	:	US
Telephone Number	:	215-341-1020
Fax Number	:

Authorized Official
Title or Position	:	MANAGING AGENT
Name	:	MRS. DANIELLE CHRISTINE DARDEN
Credential	:	MS, LBSC, LPC, NCC
Telephone Number	:	215-341-1020

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	04/19/2022

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