Provider Demographics
NPI:1619178860
Name:EMANUELSON, GREG R (PHD, LPCC-S)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:R
Last Name:EMANUELSON
Suffix:
Gender:M
Credentials:PHD, LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-453-6716
Practice Address - Street 1:130 1ST ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5452
Practice Address - Country:US
Practice Address - Phone:330-833-0234
Practice Address - Fax:330-837-7705
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0002768-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0183807Medicaid