Provider Demographics
NPI:1295207462
Name:WILSON, KELLY M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9021 KIMONO RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5338
Mailing Address - Country:US
Mailing Address - Phone:512-905-0329
Mailing Address - Fax:
Practice Address - Street 1:11330 FARRAH
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-1959
Practice Address - Country:US
Practice Address - Phone:512-280-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111168235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist