Provider Demographics
NPI:1609154087
Name:WILSON, STEPHANIE A (L-SLP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:L-SLP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-2754
Mailing Address - Country:US
Mailing Address - Phone:225-391-7262
Mailing Address - Fax:
Practice Address - Street 1:1100 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-2754
Practice Address - Country:US
Practice Address - Phone:225-391-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist