Provider Demographics
NPI:1164180378
Name:PROVENZANO, EMMA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:PROVENZANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:6012 NETTLE CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3782
Mailing Address - Country:US
Mailing Address - Phone:802-688-4400
Mailing Address - Fax:
Practice Address - Street 1:501 COVIL AVE STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2678
Practice Address - Country:US
Practice Address - Phone:910-792-6706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-05
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MA78102235Z00000X
NC15389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist