Provider Demographics
NPI:1154819308
Name:WILSON, COURTNEY SUBLETT (MS)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:SUBLETT
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 COURT ST
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1603
Mailing Address - Country:US
Mailing Address - Phone:434-515-5000
Mailing Address - Fax:
Practice Address - Street 1:4641 LOCKSVIEW RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-1935
Practice Address - Country:US
Practice Address - Phone:434-665-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid