Provider Demographics
NPI:1417233776
Name:WILSON, ELIZABETH BROOK (MS CFY-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:BROOK
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 CLARKSON RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5065
Mailing Address - Country:US
Mailing Address - Phone:636-532-4560
Mailing Address - Fax:
Practice Address - Street 1:8835 MONROVIA ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-3540
Practice Address - Country:US
Practice Address - Phone:913-383-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011032481235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist