MEDICARE: DR. ELLEN N EMERSON PH.D

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	106H00000X	Marriage & Family Therapist	MFT 0374	NV
2	103TC0700X	Clinical Psychologist	PSY002041	GA

General Provider Information

NPI Number	:	1225133838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN N EMERSON PH.D

Provider Business Mailing Address
First Line	:	112N COLLEGE ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5309
Country	:	US
Telephone Number	:	912-764-3595
Fax Number	:	912-764-3595

Provider Business Practice Location Address
First Line	:	112 N COLLEGE ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5309
Country	:	US
Telephone Number	:	912-687-5194
Fax Number	:	912-681-0834

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	09/01/2015

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