Provider Demographics
NPI:1174841068
Name:WILSON, JANET (AUD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:
Other - Last Name:LIDDICOAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:18059 HIGHWAY 105 W STE 115
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5001
Mailing Address - Country:US
Mailing Address - Phone:936-582-7000
Mailing Address - Fax:936-582-7001
Practice Address - Street 1:18059 HIGHWAY 105 W STE 115
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-5001
Practice Address - Country:US
Practice Address - Phone:936-588-7000
Practice Address - Fax:936-582-7001
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-001349231H00000X
IA000730231H00000X
IA001000237600000X
TX80539231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter