Provider Demographics
NPI:1972670131
Name:WILSON, EVA C (MS, CCC, SLP)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:C
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 1:3300 N. MCCOLL STE. A
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501
Mailing Address - Country:US
Mailing Address - Phone:956-661-0475
Mailing Address - Fax:956-688-6781
Practice Address - Street 1:3300 N MCCOLL RD STE A
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-5696
Practice Address - Country:US
Practice Address - Phone:956-661-0475
Practice Address - Fax:956-688-6781
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454597Medicare ID - Type UnspecifiedFACILITY MDCR NO.