Healthcare Provider Details

I. General information

NPI: 1295898476
Provider Name (Legal Business Name): CHILD NEUROBEHAVIORAL CENTER FOR HEALTH & WELLNESS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 BASTON RD
MARTINEZ GA
30907-2906
US

IV. Provider business mailing address

PO BOX 2854
EVANS GA
30809-2854
US

V. Phone/Fax

Practice location:
  • Phone: 706-447-8700
  • Fax: 706-447-8701
Mailing address:
  • Phone: 706-447-8700
  • Fax: 770-447-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2381
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2381
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIA E GANGAROSA EMERSON
Title or Position: OWNER
Credential: PHD
Phone: 706-447-8700