=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508247040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMILY PROGRAM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2015
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 PENNWOOD PL
-----------------------------------------------------
City | WARRENDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-364-5977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1295 BANDANA BLVD. W., SUITE 210
-----------------------------------------------------
City | ST. PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55108-5338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-364-5977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | MEREDITH TRUDGEON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-767-0274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------