Provider Demographics
NPI:1053646471
Name:WILSON, LOURDES (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SAN CARLOS RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2227
Mailing Address - Country:US
Mailing Address - Phone:213-446-8641
Mailing Address - Fax:
Practice Address - Street 1:1035 SAN CARLOS RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2227
Practice Address - Country:US
Practice Address - Phone:213-446-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-04
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist