Provider Demographics
NPI:1073121901
Name:EMERSON, GWENDOLYN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:EMERSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 WESLEYAN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3103
Mailing Address - Country:US
Mailing Address - Phone:800-603-6046
Mailing Address - Fax:317-884-3388
Practice Address - Street 1:194 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4683
Practice Address - Country:US
Practice Address - Phone:301-418-6434
Practice Address - Fax:240-566-3888
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist