Provider Demographics
NPI:1235869058
Name:ERGANG, EMILY GRACE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:ERGANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 N PUTNAM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2059
Mailing Address - Country:US
Mailing Address - Phone:978-766-6054
Mailing Address - Fax:
Practice Address - Street 1:639 GRANITE ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5366
Practice Address - Country:US
Practice Address - Phone:978-766-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-22-220306106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician