Provider Demographics
NPI:1083832489
Name:WILLSON, AMBER LYNN (MS, CCC-S)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LYNN
Last Name:WILLSON
Suffix:
Gender:F
Credentials:MS, CCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 SCOTT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9469
Mailing Address - Country:US
Mailing Address - Phone:304-763-3463
Mailing Address - Fax:
Practice Address - Street 1:130 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2648
Practice Address - Country:US
Practice Address - Phone:304-929-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0964235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist