Provider Demographics
NPI:1548508054
Name:CHRISTINE WILSON SPEECH LANGUAGE PATHOLOGY LLC
Entity type:Organization
Organization Name:CHRISTINE WILSON SPEECH LANGUAGE PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:813-956-8921
Mailing Address - Street 1:17427 BRIDGE HILL CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647
Mailing Address - Country:US
Mailing Address - Phone:813-279-2737
Mailing Address - Fax:813-279-2737
Practice Address - Street 1:5009 BELMONT RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1319
Practice Address - Country:US
Practice Address - Phone:813-956-8921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6126261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech