Provider Demographics
NPI:1528344611
Name:WILSON, LORI A
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 BAYCHESTER AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1514
Mailing Address - Country:US
Mailing Address - Phone:718-379-0429
Mailing Address - Fax:
Practice Address - Street 1:3830 PAULDING AVE.
Practice Address - Street 2:LAVELLE SCHOOL FOR THE BLIND
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469
Practice Address - Country:US
Practice Address - Phone:718-882-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013914-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist