Provider Demographics
NPI:1528216215
Name:PARK, EMILY BETH (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:BETH
Last Name:PARK
Suffix:
Gender:F
Credentials:MS 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:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-0101
Mailing Address - Country:US
Mailing Address - Phone:716-341-1630
Mailing Address - Fax:
Practice Address - Street 1:2 SCOTT ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-4724
Practice Address - Country:US
Practice Address - Phone:716-341-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015783235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist