Provider Demographics
NPI:1750629937
Name:WILSON, ELIZABETH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W HAYCRAFT AVE
Mailing Address - Street 2:SUITE D4
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8105
Mailing Address - Country:US
Mailing Address - Phone:208-664-2468
Mailing Address - Fax:208-667-6239
Practice Address - Street 1:411 W HAYCRAFT AVE
Practice Address - Street 2:SUITE D4
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8105
Practice Address - Country:US
Practice Address - Phone:208-664-2468
Practice Address - Fax:208-667-6239
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2219235Z00000X
WALL60026217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist