Organization
WMC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TAKISA S GALLMAN (ADMINISTRATIVE DIRECTOR)
(215) 276-3922
Entity
Organization
Contact information
Practice address
4913 N BROAD ST, PHILADELPHIA, PA 19141-2215
(215) 329-3200
(215) 329-3217
Mailing address
4913 N BROAD ST, PHILADELPHIA, PA 19141-2215
(215) 329-3200
(215) 329-3217
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
192780
PA
101YP2500X
Professional Counselor
192780
PA
103TC0700X
Clinical Psychologist
192780
PA
174400000X
Specialist
Primary
192780
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0016804930005
—
PA
Enumeration date
04/19/2007
Last updated
09/11/2025
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