Provider Demographics
NPI:1942292719
Name:EMERSON, M. THERESA (PSYD)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:THERESA
Last Name:EMERSON
Suffix:
Gender:F
Credentials:PSYD
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 21594
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-1594
Mailing Address - Country:US
Mailing Address - Phone:254-776-3632
Mailing Address - Fax:254-776-8181
Practice Address - Street 1:6609 SANGER AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4252
Practice Address - Country:US
Practice Address - Phone:254-776-3632
Practice Address - Fax:254-776-8181
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J50POtherBLUE CROSS BLUE SHIELD