Provider Demographics
NPI:1760668222
Name:WILSON, CHRISTIE M (SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2811 LONGVIEW DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5919
Mailing Address - Country:US
Mailing Address - Phone:870-974-9114
Mailing Address - Fax:870-974-9184
Practice Address - Street 1:1801 GRANT AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6155
Practice Address - Country:US
Practice Address - Phone:870-974-9114
Practice Address - Fax:870-974-9184
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP2523235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist