Provider Demographics
NPI:1902039845
Name:WILSON, JOHNNIE V (SLP)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:V
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 REGIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3551
Mailing Address - Country:US
Mailing Address - Phone:662-513-7750
Mailing Address - Fax:662-234-1699
Practice Address - Street 1:967 REGIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3551
Practice Address - Country:US
Practice Address - Phone:662-513-7750
Practice Address - Fax:662-234-1699
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3181235Z00000X
MS197970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist