MEDICARE: ELLEN N. EMERSON, PHD, 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	103TC0700X	Clinical Psychologist	PSY002041	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700045937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLEN N. EMERSON, PHD, LLC

Provider Business Mailing Address
First Line	:	112 N 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	:	912-764-3595
Fax Number	:	912-764-3595

Authorized Official
Title or Position	:	OWNER
Name	:	ELLEN N. EMERSON
Credential	:	PHD
Telephone Number	:	912-764-3595

Provider Enumeration Date	:	06/03/2008
Last Update Date	:	06/03/2008

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