Provider Demographics
NPI:1235786054
Name:WILSON, ANGELINA MARIA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:MARIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:MARIA
Other - Last Name:TUTLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:5800 GRANITE PKWY STE 1000
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1431
Practice Address - Country:US
Practice Address - Phone:715-762-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4611-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist