Provider Demographics
NPI:1861779167
Name:WILSON, KATIE (MS CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 MARLEIGH LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3051
Mailing Address - Country:US
Mailing Address - Phone:309-532-4322
Mailing Address - Fax:
Practice Address - Street 1:700 N MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1442
Practice Address - Country:US
Practice Address - Phone:224-253-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist