Provider Demographics
NPI:1356486443
Name:WILSON, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5947
Mailing Address - Country:US
Mailing Address - Phone:870-240-4966
Mailing Address - Fax:
Practice Address - Street 1:821 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5947
Practice Address - Country:US
Practice Address - Phone:870-240-4966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1487225200000X
ARSP2304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist