Provider Demographics
NPI:1073833133
Name:WILSON, NICOLE S (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FRONTAGE RD
Mailing Address - Street 2:SUITE 2415
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1202
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:201 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4409
Practice Address - Country:US
Practice Address - Phone:217-235-5449
Practice Address - Fax:217-235-0611
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist