=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467114553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGE COUNSELING AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2021
-----------------------------------------------------
Last Update Date | 10/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9736 LUGUNA RD
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-622-3886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9736 LUGUNA RD
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-206-1758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | ALICIA PEARSON
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 410-622-3186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------