Provider Demographics
NPI:1124780739
Name:EMERSON, CHANDLER
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:EMERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 AVON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4936
Mailing Address - Country:US
Mailing Address - Phone:916-316-5039
Mailing Address - Fax:
Practice Address - Street 1:1358 BLUE OAKS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7040
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician