Provider Demographics
NPI:1083603997
Name:WILSON, DANA (MA)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7002
Mailing Address - Country:US
Mailing Address - Phone:812-855-7439
Mailing Address - Fax:812-855-5561
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-855-7439
Practice Address - Fax:812-855-5561
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002148A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11512048OtherCAQH PROVIDER ID
IN11512048OtherCAQH PROVIDER ID