Provider Demographics
NPI:1518626365
Name:WILSON, ELIZABETH BROOKE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8887 HIGHWAY 13 N
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:MS
Mailing Address - Zip Code:39094-9782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 KIRKLAND ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-3205
Practice Address - Country:US
Practice Address - Phone:601-774-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist