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General NPI Number Information
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NPI Number | 1083906994
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Entity Type | Organization
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Legal Business Name | EMILY PROGRAM PC
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Dates
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Enumeration Date | 05/11/2011
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 2230 COMO AVE
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City | SAINT PAUL
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State | MN
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Zip | 55108-1720
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Country | US
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Telephone | 651-645-5323
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Fax |
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Provider Business Mailing Address
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Address Line | 2265 COMO AVE
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City | SAINT PAUL
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State | MN
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Zip | 55108-1737
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Country | US
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Telephone | 651-645-5323
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DIRK A MILLER
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Credential | PHD, LP
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Telephone | 651-645-5323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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