MEDICARE: EMERALD PSYCHOLOGICAL SERVICES, LLC

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	103T00000X	Psychologist		SD

General Provider Information

NPI Number	:	1346644432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	5032 S BUR OAK PL
Second Line	:	STE. 120
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2243
Country	:	US
Telephone Number	:	605-362-2617
Fax Number	:	605-362-2654

Provider Business Practice Location Address
First Line	:	5032 S BUR OAK PL
Second Line	:	STE. 120
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-2243
Country	:	US
Telephone Number	:	605-362-2617
Fax Number	:	605-362-2654

Authorized Official
Title or Position	:	OWNER/PSYCHOLOGIST
Name	:	DR. JEREMY L JOHNSON
Credential	:	PHD
Telephone Number	:	605-362-2617

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/17/2014

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