Healthcare Provider Details

I. General information

NPI: 1619766060
Provider Name (Legal Business Name): EMILIE WANKO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 PINEWIND DR
ALBURTIS PA
18011-2703
US

IV. Provider business mailing address

1605 PINEWIND DR
ALBURTIS PA
18011-2703
US

V. Phone/Fax

Practice location:
  • Phone: 570-299-0540
  • Fax:
Mailing address:
  • Phone: 570-299-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: