Provider Demographics
NPI:1588800932
Name:WILSON, DEBORAH JAN (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:JAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 10
Mailing Address - Street 2:
Mailing Address - City:TIERRA AMARILLA
Mailing Address - State:NM
Mailing Address - Zip Code:87575
Mailing Address - Country:US
Mailing Address - Phone:575-588-7297
Mailing Address - Fax:575-588-7970
Practice Address - Street 1:STATE RD 531
Practice Address - Street 2:CHAMA VALLEY SCHOOLS
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575
Practice Address - Country:US
Practice Address - Phone:575-588-7297
Practice Address - Fax:575-588-7970
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4440235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist