MEDICARE: PHILLYCARE COACHING 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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1881388999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLYCARE COACHING LLC

Provider Business Mailing Address
First Line	:	21 ASHMEAD PL N
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2916
Country	:	US
Telephone Number	:	267-375-9131
Fax Number	:	267-787-1142

Provider Business Practice Location Address
First Line	:	21 ASHMEAD PL N
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2916
Country	:	US
Telephone Number	:	267-375-9131
Fax Number	:	267-787-1142

Authorized Official
Title or Position	:	OWNER, OCCUPATIONAL THERAPIST
Name	:	EMILY SANDRA GAVIN
Credential	:	MS, OTR/L
Telephone Number	:	267-375-9131

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	01/31/2024

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