Provider Demographics
NPI:1912183161
Name:WILSON, LAURA CHRISTINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
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 1:721 E MOUNT ELDEN LOOKOUT RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7845
Mailing Address - Country:US
Mailing Address - Phone:928-773-9192
Mailing Address - Fax:
Practice Address - Street 1:721 E MOUNT ELDEN LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7845
Practice Address - Country:US
Practice Address - Phone:928-773-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist