Provider Demographics
NPI:1346387099
Name:WILSON, REBECCA RAE (MA, CCC-SP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 E LYNX WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3010
Mailing Address - Country:US
Mailing Address - Phone:480-883-9167
Mailing Address - Fax:
Practice Address - Street 1:1525 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6178
Practice Address - Country:US
Practice Address - Phone:480-812-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2101235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ801490OtherAHCCS PROVIDER #