Provider Demographics
NPI:1679044937
Name:WILSON-FAVORS, VANESSA (MS, CCC-SLP/AUD)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:
Last Name:WILSON-FAVORS
Suffix:
Gender:F
Credentials:MS, CCC-SLP/AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3036
Mailing Address - Country:US
Mailing Address - Phone:301-322-4628
Mailing Address - Fax:
Practice Address - Street 1:6008 FOREST RD
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-3036
Practice Address - Country:US
Practice Address - Phone:301-322-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist