Provider Demographics
NPI:1700045937
Name:ELLEN N. EMERSON, PHD, LLC
Entity Type:Organization
Organization Name:ELLEN N. EMERSON, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-764-3595
Mailing Address - Street 1:112 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5309
Mailing Address - Country:US
Mailing Address - Phone:912-764-3595
Mailing Address - Fax:912-764-3595
Practice Address - Street 1:112 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5309
Practice Address - Country:US
Practice Address - Phone:912-764-3595
Practice Address - Fax:912-764-3595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002041103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA682757187AMedicaid
GA68BBGSSMedicare PIN