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General NPI Number Information
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NPI Number | 1295898476
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Entity Type | Organization
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Legal Business Name | CHILD NEUROBEHAVIORAL CENTER FOR HEALTH & WELLNESS, PC
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 302 BASTON RD
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City | MARTINEZ
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State | GA
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Zip | 30907-2906
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Country | US
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Telephone | 706-447-8700
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Fax | 706-447-8701
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Provider Business Mailing Address
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Address Line | PO BOX 2854
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City | EVANS
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State | GA
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Zip | 30809-2854
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Country | US
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Telephone | 706-447-8700
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Fax | 770-447-8701
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARIA E GANGAROSA EMERSON
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Credential | PHD
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Telephone | 706-447-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 2381
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2381
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License Number State | GA
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