Healthcare Provider Details

I. General information

NPI: 1124711692
Provider Name (Legal Business Name): EMALINE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 TOWNE PARK DR W STE 103
RINCON GA
31326-9098
US

IV. Provider business mailing address

6600 FRANCE AVE S STE 350
EDINA MN
55435-1810
US

V. Phone/Fax

Practice location:
  • Phone: 912-208-4776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-275970
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: