MEDICARE: EMOTIONAL WELLNESS CLINIC PLLC

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	103TC0700X	Clinical Psychologist	PS017475	PA

General Provider Information

NPI Number	:	1659720738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMOTIONAL WELLNESS CLINIC PLLC

Provider Business Mailing Address
First Line	:	3720 SPRUCE ST
Second Line	:	# 418
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4115
Country	:	US
Telephone Number	:	215-600-3557
Fax Number	:	215-600-3557

Provider Business Practice Location Address
First Line	:	3720 SPRUCE ST
Second Line	:	# 418
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4115
Country	:	US
Telephone Number	:	215-600-3557
Fax Number	:	215-600-3557

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. PETER MATTHEW VERNIG
Credential	:	PHD
Telephone Number	:	215-600-3557

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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