MEDICARE: EMMANUEL BEHAVIORAL HEALTH & WELLNESS PLLC

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	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist

General Provider Information

NPI Number	:	1760338727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMANUEL BEHAVIORAL HEALTH & WELLNESS PLLC

Provider Business Mailing Address
First Line	:	1328 HERITAGE BLVD
Second Line	:	0FFICE # 5
City	:	LONGVIEW
State	:	TX
Zip	:	75605-1472
Country	:	US
Telephone Number	:	903-260-0412
Fax Number	:

Provider Business Practice Location Address
First Line	:	1328 HERITAGE BLVD # 5
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-1472
Country	:	US
Telephone Number	:	903-260-0412
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	LATONYA POLK
Credential	:	PMHNP-BC
Telephone Number	:	903-315-8302

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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