Provider Demographics
NPI:1477026763
Name:WILSON, CARLY R (MS)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 S 15TH PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7286
Mailing Address - Country:US
Mailing Address - Phone:972-741-4393
Mailing Address - Fax:
Practice Address - Street 1:2614 S 15TH PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7286
Practice Address - Country:US
Practice Address - Phone:972-741-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist