Provider Demographics
NPI:1790301018
Name:WILSON, CAROLINE K (BA, MCD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:BA, MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHARLESTON PARK
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-3966
Mailing Address - Country:US
Mailing Address - Phone:337-274-3890
Mailing Address - Fax:
Practice Address - Street 1:4600 RIVER RD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-1943
Practice Address - Country:US
Practice Address - Phone:504-349-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1701033Medicaid