Provider Demographics
NPI:1144437989
Name:GANGAROSA-EMERSON, MARIA E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:E
Last Name:GANGAROSA-EMERSON
Suffix:
Gender:F
Credentials:PHD
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 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:706-447-8701
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY 0002381103TC0700X
GA2381103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000852277BMedicaid
GA020657518001OtherFED TAX ID
GA52669312-001OtherINS ID
GA020657518OtherFED TAX ID
GA52669312-001OtherINS ID
GA020657518OtherFED TAX ID