Provider Demographics
NPI:1275186207
Name:WMC
Entity Type:Organization
Organization Name:WMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAKISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-276-3922
Mailing Address - Street 1:1939 S JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2217
Mailing Address - Country:US
Mailing Address - Phone:215-271-5822
Mailing Address - Fax:215-276-1249
Practice Address - Street 1:1939 S JUNIPER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2217
Practice Address - Country:US
Practice Address - Phone:215-271-5822
Practice Address - Fax:215-271-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001680493Medicaid