MEDICARE: ALICE D GRESHAM M.A.

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
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1891315453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE D GRESHAM M.A.

Provider Business Mailing Address
First Line	:	2025 CONLYN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-2925
Country	:	US
Telephone Number	:	936-662-7478
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 CONLYN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-2925
Country	:	US
Telephone Number	:	936-662-7478
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	04/23/2020

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Directions to “ ALICE D GRESHAM M.A.” Practice Location

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