Provider Demographics
NPI:1649572371
Name:WILSON, MICHELLE DAVIS (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DAVIS
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CCC
Mailing Address - Street 1:9 SWAN CT
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-1634
Mailing Address - Country:US
Mailing Address - Phone:856-761-7834
Mailing Address - Fax:
Practice Address - Street 1:9 SWAN CT
Practice Address - Street 2:
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-1634
Practice Address - Country:US
Practice Address - Phone:856-761-7834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010074235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist