Provider Demographics
NPI:1477636546
Name:GEOGHEGAN, EMILY BERNICE (MDIV, PHD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:BERNICE
Last Name:GEOGHEGAN
Suffix:
Gender:F
Credentials:MDIV, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2834
Mailing Address - Country:US
Mailing Address - Phone:603-627-2702
Mailing Address - Fax:603-627-3643
Practice Address - Street 1:2013 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2528
Practice Address - Country:US
Practice Address - Phone:603-627-2702
Practice Address - Fax:603-627-3643
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH992103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010179Medicaid
NHGERE7146Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL