Provider Demographics
NPI:1902118342
Name:WILSON, KRISTEN DANIELLE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DANIELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DANIELLE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18537 W ONYX AVE
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-4446
Mailing Address - Country:US
Mailing Address - Phone:480-330-7661
Mailing Address - Fax:
Practice Address - Street 1:17958 W BROWN ST
Practice Address - Street 2:PROGRESSIVE THERAPY LLC
Practice Address - City:WADDELL
Practice Address - State:AZ
Practice Address - Zip Code:85355-4151
Practice Address - Country:US
Practice Address - Phone:623-535-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6787235Z00000X
AZSLP6787235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist