Provider Demographics
NPI:1114536588
Name:EMERSON, BENJAMIN BRADLEY (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRADLEY
Last Name:EMERSON
Suffix:
Gender:M
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 1:1101 RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-8040
Mailing Address - Country:US
Mailing Address - Phone:405-308-8146
Mailing Address - Fax:
Practice Address - Street 1:1101 RED BUD LN
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-8040
Practice Address - Country:US
Practice Address - Phone:405-308-8146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist