MEDICARE: EMILY STRALEY EDS

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	103TS0200X	School Psychologist	10250345	IN

General Provider Information

NPI Number	:	1508699075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY STRALEY EDS

Provider Business Mailing Address
First Line	:	10441 CLAY SPRING PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8736
Country	:	US
Telephone Number	:	765-469-0770
Fax Number	:

Provider Business Practice Location Address
First Line	:	13119 COLDWATER RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9631
Country	:	US
Telephone Number	:	260-637-3155
Fax Number	:

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

Provider Enumeration Date	:	08/21/2024
Last Update Date	:	08/21/2024

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