MEDICARE: TINA MARIE EMERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP0016X	Prescribing (Medical) Psychologist		AR

General Provider Information

NPI Number	:	1154511640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA MARIE EMERSON

Provider Business Mailing Address
First Line	:	5703 CENTRAL AVE
Second Line	:	#11
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-1824
Country	:	US
Telephone Number	:	501-520-5019
Fax Number	:

Provider Business Practice Location Address
First Line	:	5703 CENTRAL AVE
Second Line	:	#11
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-1824
Country	:	US
Telephone Number	:	501-520-5019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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