MEDICARE: EDM COUNSELING AND WELLNESS

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1912761131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDM COUNSELING AND WELLNESS

Provider Business Mailing Address
First Line	:	3148 DERRY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2518
Country	:	US
Telephone Number	:	215-584-7393
Fax Number	:

Provider Business Practice Location Address
First Line	:	3148 DERRY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19154-2518
Country	:	US
Telephone Number	:	215-584-7393
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELLISE MILBURN
Credential	:	LPC
Telephone Number	:	215-584-7393

Provider Enumeration Date	:	02/08/2024
Last Update Date	:	02/08/2024

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