Healthcare Provider Details

I. General information

NPI: 1144437989
Provider Name (Legal Business Name): MARIA E GANGAROSA-EMERSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 02/19/2012
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: 706-447-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2381
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 0002381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: