Provider Demographics
NPI:1497005888
Name:WILSON, LAURIE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MONTE ELMA RD
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9021
Mailing Address - Country:US
Mailing Address - Phone:360-482-1123
Mailing Address - Fax:360-482-3963
Practice Address - Street 1:1235 MONTE ELMA RD
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9021
Practice Address - Country:US
Practice Address - Phone:360-482-1123
Practice Address - Fax:360-482-3963
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001507235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist