Provider Demographics
NPI:1376120170
Name:WILSON, RACHEL A (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 ALEXANDER DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9069
Mailing Address - Country:US
Mailing Address - Phone:812-459-7769
Mailing Address - Fax:
Practice Address - Street 1:6317 HIGHWAY 329
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9040
Practice Address - Country:US
Practice Address - Phone:502-384-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY140603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist