Provider Demographics
NPI:1538759477
Name:WILSON, KASSANDRA
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
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 1:1309 PENNSYLVANIA AVE W
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-1921
Mailing Address - Country:US
Mailing Address - Phone:814-730-4261
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH POINT DR
Practice Address - Street 2:
Practice Address - City:KANE
Practice Address - State:PA
Practice Address - Zip Code:16735-9704
Practice Address - Country:US
Practice Address - Phone:670-681-4837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist