Provider Demographics
NPI:1881407047
Name:LINE, EMMETT CHARLES (LAC)
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:CHARLES
Last Name:LINE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627-2005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:DEMAREST
Practice Address - State:NJ
Practice Address - Zip Code:07627-2005
Practice Address - Country:US
Practice Address - Phone:608-516-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00559100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health