Provider Demographics
NPI:1053050344
Name:EMBRACING MY BLACK PEN
Entity Type:Organization
Organization Name:EMBRACING MY BLACK PEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SELEME
Authorized Official - Middle Name:
Authorized Official - Last Name:GILCHRIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-809-5433
Mailing Address - Street 1:7182 N UBER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 WASHINGTON LN STE 304
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3148
Practice Address - Country:US
Practice Address - Phone:267-809-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty