Provider Demographics
NPI:1295232098
Name:EMORY, KANESSIA Q
Entity Type:Individual
Prefix:
First Name:KANESSIA
Middle Name:Q
Last Name:EMORY
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 1:4631 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5037
Mailing Address - Country:US
Mailing Address - Phone:407-285-8139
Mailing Address - Fax:
Practice Address - Street 1:755 27TH AVE SW STE 9&10
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-4200
Practice Address - Country:US
Practice Address - Phone:407-285-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE560-515-91-790-0OtherPROVIDE INSURANCE
FLE560-515-91-790-0Medicaid