MEDICARE: EMERALD ISLE HEALTH AND WELLNESS

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	103TP2701X	Group Psychotherapy Psychologist

General Provider Information

NPI Number	:	1639826837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD ISLE HEALTH AND WELLNESS

Provider Business Mailing Address
First Line	:	4301 S PINE ST STE 17
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7252
Country	:	US
Telephone Number	:	720-204-8510
Fax Number	:	720-828-6114

Provider Business Practice Location Address
First Line	:	4301 S PINE ST STE 17
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7252
Country	:	US
Telephone Number	:	720-204-8510
Fax Number	:	720-828-6114

Authorized Official
Title or Position	:	OWNER
Name	:	SHARON L. ALLEN
Credential	:	PHD
Telephone Number	:	720-204-8510

Provider Enumeration Date	:	03/07/2022
Last Update Date	:	03/07/2022

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