Provider Demographics
NPI:1245798487
Name:WILSON, KATHERINE DENISE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 QUINN DR NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1489
Mailing Address - Country:US
Mailing Address - Phone:252-218-9476
Mailing Address - Fax:
Practice Address - Street 1:1901 TARBORO ST SW STE 301
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3479
Practice Address - Country:US
Practice Address - Phone:919-719-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11874235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist