=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699566455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA NISBET CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 S BEDFORD ST STE 101W
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01803-5152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-865-9445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 SANGER ST APT 3
-----------------------------------------------------
City | SOUTH BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02127-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-806-6991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP101143
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------