Provider Demographics
NPI:1245771930
Name:EMERGENT COMMUNITY DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:EMERGENT COMMUNITY DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:214-432-8296
Mailing Address - Street 1:1140 EMPIRE CENTRAL DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4322
Mailing Address - Country:US
Mailing Address - Phone:214-432-8296
Mailing Address - Fax:214-203-0803
Practice Address - Street 1:1140 EMPIRE CENTRAL DR
Practice Address - Street 2:SUITE 260
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4322
Practice Address - Country:US
Practice Address - Phone:214-432-8296
Practice Address - Fax:214-203-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12479251B00000X
TX15397251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX311514901Medicaid
TX311515601Medicaid