Basic Information
Provider Information | |||||||||
NPI: | 1518998012 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EMERY | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 32 WHISPER CREEK DR | ||||||||
Address2: | SUITE 7 | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178377770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705220304 | ||||||||
FaxNumber: | 5705220475 | ||||||||
Practice Location | |||||||||
Address1: | 32 WHISPER CREEK DR | ||||||||
Address2: | SUITE 7 | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178377770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705220304 | ||||||||
FaxNumber: | 5705220475 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 12/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PS015898 | PA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | EM1824598 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1015206250001 | 05 | PA |   | MEDICAID |