Provider Demographics
NPI:1861652265
Name:WILSON, CHRISTINE ANN (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647
Mailing Address - Country:US
Mailing Address - Phone:813-279-2737
Mailing Address - Fax:813-279-2737
Practice Address - Street 1:5383 PRIMROSE LAKE CIR STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3520
Practice Address - Country:US
Practice Address - Phone:813-279-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12026483OtherASHA