MEDICARE: EMERALD LIGHT

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1801727664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMERALD LIGHT

Provider Business Mailing Address
First Line	:	3253 INDIAN RIPPLE RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-3632
Country	:	US
Telephone Number	:	937-654-3986
Fax Number	:

Provider Business Practice Location Address
First Line	:	1375 KEMPER MEADOW DR STE 12
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-1650
Country	:	US
Telephone Number	:	513-294-8330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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Directions to “ EMERALD LIGHT ” Practice Location

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