Provider Demographics
NPI:1730244799
Name:WILSON, LAURA LYNN (CCC-SLP, MED)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 MCDONALD CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-6208
Mailing Address - Country:US
Mailing Address - Phone:229-432-2273
Mailing Address - Fax:
Practice Address - Street 1:196 MCDONALD CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-6208
Practice Address - Country:US
Practice Address - Phone:229-432-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004672235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist