Provider Demographics
NPI:1861002461
Name:MATERNAL WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MATERNAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WICKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, PHM-C
Authorized Official - Phone:267-432-2374
Mailing Address - Street 1:88 W WASHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2602
Mailing Address - Country:US
Mailing Address - Phone:267-432-2374
Mailing Address - Fax:
Practice Address - Street 1:67 BYBERRY RD
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-3205
Practice Address - Country:US
Practice Address - Phone:215-649-9916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health