Provider Demographics
NPI:1174846455
Name:WILSON, BRANDY L
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BRANDY
Other - Middle Name:L
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:836 S BISHOP ST
Mailing Address - Street 2:GARDEN APT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4022
Mailing Address - Country:US
Mailing Address - Phone:814-598-9729
Mailing Address - Fax:
Practice Address - Street 1:836 S BISHOP ST
Practice Address - Street 2:GARDEN APT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4022
Practice Address - Country:US
Practice Address - Phone:814-598-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBRANDY0936Medicaid
ILBRANDY0936Medicare Oscar/Certification
ILBRANDY0936Medicare UPIN
ILBRANDY0936Medicare PIN