Provider Demographics
NPI:1659786176
Name:WASSILAK, EMMA (MED, LPC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:WASSILAK
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:BROMME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPC
Mailing Address - Street 1:1100 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-4450
Mailing Address - Country:US
Mailing Address - Phone:405-609-8949
Mailing Address - Fax:
Practice Address - Street 1:1100 NW 14TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-4450
Practice Address - Country:US
Practice Address - Phone:405-609-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200540070AMedicaid