Healthcare Provider Details

I. General information

NPI: 1508247040
Provider Name (Legal Business Name): EMILY PROGRAM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 08/04/2025
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PENNWOOD PL
WARRENDALE PA
15086
US

IV. Provider business mailing address

1295 BANDANA BLVD. W., SUITE 210
ST. PAUL MN
55108-5338
US

V. Phone/Fax

Practice location:
  • Phone: 888-364-5977
  • Fax:
Mailing address:
  • Phone: 866-364-5977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MEREDITH TRUDGEON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-767-0274