Provider Demographics
NPI:1598031916
Name:WILSON, VICKI (MS)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
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 1:22 TROWBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-1024
Mailing Address - Country:US
Mailing Address - Phone:617-818-5704
Mailing Address - Fax:
Practice Address - Street 1:35 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2866
Practice Address - Country:US
Practice Address - Phone:508-580-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA327231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist