Provider Demographics
NPI:1043354079
Name:WILKERSON, GENA RAE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GENA
Middle Name:RAE
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 BRADLEY ROAD 39
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71647-9107
Mailing Address - Country:US
Mailing Address - Phone:870-814-0608
Mailing Address - Fax:
Practice Address - Street 1:459 BRADLEY ROAD 39
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:AR
Practice Address - Zip Code:71647-9107
Practice Address - Country:US
Practice Address - Phone:870-814-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist