Provider Demographics
NPI:1336496256
Name:ANDEM, EMMA IME
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:IME
Last Name:ANDEM
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:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32447-0844
Mailing Address - Country:US
Mailing Address - Phone:850-557-9202
Mailing Address - Fax:
Practice Address - Street 1:2944 PENN AVE STE L
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-2741
Practice Address - Country:US
Practice Address - Phone:850-526-5500
Practice Address - Fax:850-526-5536
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 112971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008993500Medicaid