Provider Demographics
NPI:1295898476
Name:CHILD NEUROBEHAVIORAL CENTER FOR HEALTH & WELLNESS, PC
Entity type:Organization
Organization Name:CHILD NEUROBEHAVIORAL CENTER FOR HEALTH & WELLNESS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GANGAROSA EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-447-8700
Mailing Address - Street 1:PO BOX 2854
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2854
Mailing Address - Country:US
Mailing Address - Phone:706-447-8700
Mailing Address - Fax:770-447-8701
Practice Address - Street 1:302 BASTON RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2906
Practice Address - Country:US
Practice Address - Phone:706-447-8700
Practice Address - Fax:706-447-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2381103G00000X, 103T00000X
235Z00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52669312-001OtherBCBS
GA000852277BMedicaid
GA000852277BMedicaid
GA52669312-001OtherBCBS
GAQ22624Medicare UPIN
GA000852277BMedicaid