Provider Demographics
NPI:1467543983
Name:WILSON, HEATHER ROSE (MA CCCSLP)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-4601
Mailing Address - Country:US
Mailing Address - Phone:440-465-9522
Mailing Address - Fax:
Practice Address - Street 1:232 W 25TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16544-0002
Practice Address - Country:US
Practice Address - Phone:814-452-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL012682OtherPA SLP LICENSE
12093686OtherASHA