Provider Demographics
NPI:1568094449
Name:ANDERSON, EMANUEL MALIK
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:MALIK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3097
Mailing Address - Country:US
Mailing Address - Phone:478-825-6499
Mailing Address - Fax:
Practice Address - Street 1:410 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3097
Practice Address - Country:US
Practice Address - Phone:478-825-6499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health