Provider Demographics
NPI:1013096239
Name:WILSON, MICHELE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
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 1:3205 WENDOVER DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1863
Mailing Address - Country:US
Mailing Address - Phone:419-241-6219
Mailing Address - Fax:419-241-5912
Practice Address - Street 1:3148 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2920
Practice Address - Country:US
Practice Address - Phone:419-241-6219
Practice Address - Fax:419-241-5912
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-7435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist