Provider Demographics
NPI:1275685687
Name:WILSON, MANDI (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
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 1:4414 W SAN CARLOS ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5544
Mailing Address - Country:US
Mailing Address - Phone:813-601-0497
Mailing Address - Fax:
Practice Address - Street 1:2401 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4434
Practice Address - Country:US
Practice Address - Phone:813-988-7633
Practice Address - Fax:813-237-8593
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist